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I 



Property of the 

Lancaster City and County 
Medical Society 



No 



win 



THE 



AMEEICAN JOURNAL 

OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA; ASSOCIATE FELLOW 
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, 

&c. &c. &c. 



NEW SERIES. 
YOL. XLIY. 




PHILADELPHIA: 
B L A N C H A R D AND LEA. 
1862. 



69470 



Entered according to tlie Act of Congress, in the year 1862, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA : 
COLLINS, PRINTEE. 



AblS 
Med. 

TO READERS AND CORRESPONDENTS. 

We have received a letter from Dr. W. F. Wade, of Birmingham, England, 
the author of "a very interesting case of Aortic Aneurism, in which a commu- 
nication with the pulmonary artery was recognized during life by means of 
Physical Diagnosis," published in the volume of Medico-Chirurgical Transac- 
tions for 1861, and reviewed in our No. for April last, p. 473, calling our atten- 
tion to a misprint of his name. We regret this mistake, and will ask our sub- 
scribers to correct it in their copies. 

The following works have been received : — 

Transactions of the Obstetrical Society of London. Yol. lY. For the year 
1861. With a list of Officers, Fellows, &c. London : Longman & Co., 1862. 
(From the Society.) 

Public Health in relation to Air and Water. By W. T. Gairdner, M. D., 
F. R. C. P. E., Lecturer on the Practice of Medicine, &c. Edinburgh : Edmon- 
ston & Douglass, 1862. (From the Author.) 

On Intestinal Obstruction by the Solitary Band. Being a paper read at a 
meeting of the Medical Society of London, March 25, 1861, and reprinted from 
their Transactions. By John Gay, F. R. C. S., Surgeon to the Great -Northern 
Hospital, &c. &c. London, 1861. (From the Author.) 

De r Application de la Suture Enchevillee a 1' Operation de I'Entropion Spas- 
modique au Moyen d'une Nouvelle Esp^ce de Cheville (cheville jumelle ou a 
double branche). Par F. Yauquelin, M6decin Oculists et Auriste a Paris, &c. 
Paris : Germer-Bailli^re, 1853. (From the Author.) 

Rapport fait a la Society Universelle d' Ophthalmologic par le Secretaire Pro- 
visoire. F. Yauquelin, et Descours d'Ouverture par Francesco de Argelagos. 
Yersailles, 1861. 

A Manual of Medical Diagnosis : being an Analysis of the Signs and Symptoms 
of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant Physician to St. 
George's Hospital, &c. &c. Second American from the second and revised 
London edition. Philadelphia : Blanchard & Lea, 1862. (From the Publishers.) 

Handbook of Surgical Operations. By Stephen Smith, M. D., Surgeon to 
Bellevue Hospital, New York. Bailli^re Brothers, 1862. (From the Author.) 

A Practical Guide to the Study of the Diseases of the Eye : their Medical 
and Surgical Treatment. By Henry W. Williams, M. D., Fellow Massachu- 
setts Medical Society, &c. &c. Boston : Ticknor & Fields, 1862. 

Experiments and Observations upon the Circulation in the Snapping Turtle, 
Chelonura Serpentina, with especial reference to the Pressure of the Blood in 
the Arteries and Yeins. By S'. Wier Mitchell, M. D., Lecturer on Physiology. 
Philadelphia, 1862. (From the Author.) 

A Description of the Newly Invented Elastic Tourniquet, for the Use of 
Armies and Employment in Civil Life : its Uses and Applications, with Remarks 
on the different Methods of arresting Hemorrhage from Gunshot and other 
Wounds. New York, 1862. 



8 



TO READERS AND CORRESPONDENTS. 



Extension and Counter Extension in the Treatment of Fractures of the Long 
Bones, with a description of an Apparatus especially designed for Compound 
Fractures. By Joseph H. Vedder, M. D. Flushing, L. I. New York, 1862. 

Advice to a Mother on the Management of her Offspring. By Pye Henry 
Chavasse, F, R. C. S., &c. &c. Reprinted from the sixth London edition. New 
York : Ballifere Brothers, 1862. 

Quarterly Summary of the Transactions of the College of Physicians of 
Philadelphia.. From September 4, 1861, to February 5, 1862, inclusive. Phila- 
delphia, 1862. 

Proceedings of the Academy of Natural Sciences of Philadelphia. January, 
February, March, April, 1862. 

Mortuary Tables of San Francisco. Arranged by A. F. Sawyer, M. D., 
January, 1862. San Francisco, 1862. (From the Author.) 

The Action of the Voluntary Muscles. By Louis Mackall, M. D. Alexan- 
dria, 1862. (From the Author.) 

The Annual Address before the Medical Society of the State of New York, 
and the Members of the Legislature, delivered in the Capitol, February 6, 1862. 
By Edward H. Parker, M. D., President of Society. Poughkeepsie, 1862. 
(From the Author.) 

Address before the Philadelphia County Medical Society. Delivered Jan- 
uary 30, 1862. By Joseph Carson, M. D., at the close of his official term as 
President. Printed by order of the Society. Philadelphia, 1862. (From the 
Author.) 

An Address delivered before the BuflFalo Medical Association, April 1, 1862. 
By Dr. C. C. F. Gay, President of the Association, on retiring from the chair. 
Published by vote of the Association. Buffalo, 1862. 

Valedictory Address to the Graduating Class of the Cincinnati College of 
Medicine and Surgery. Delivered February 12, 1862. By A. H. Baker, M. D., 
Professor of Surgery. Cincinnati, 1862. 

Forty-fifth Annual Report on the State of the Asylum for the Relief of Per- 
sons deprived of their Reason. Published by direction of the Contributors. 
Philadelphia, 1862. (From Dr. J. H. Worthington, Physician and Superin- 
tendent.) 

Second Annual Report of the Superintendent of Clifton Hall, a Private 
Hospital for Mental Diseases, to the Board of Supervision, for the year 1861. 
Philadelphia, 1862. (From R. A. Given, M. D.) 

Fourth Annual Report of the Medical Board of the Charity Hospital of 
Philadelphia to the Board of Trustees, January 1, 1862. Philadelphia, 1862. 
(From Dr. A. M. Slocum.) 

The following Journals have been received in exchange : — 
Gazette M6dicale de Paris. February, March, 1862. 

Annales Medico-Psychologiques. Redege par MM. les Docteurs Baillarger, 
Cerise, et Moreau (de Tours). January, 1862. 



TO READERS AND CORRESPONDENTS. 



9 



Gazette Hebdomadaire de Medecine et de Chirurgie. Redacteur en chef, A. " 
Dechambre. Tom. IX., Nos. 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 
18, 20, 21, 22. 1862. 

Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. January, 
February, March, 1862. 

Edinburgh Medical Journal. March, April, 1862. 

British and Foreign Medico-Chirurgical Review. April, 1862. 

The Glasgow Medical Journal. April, 1862. 

The Dublin Quarterly Journal of Medical Science. May, 1862. 

Medical Times and Gazette. April, May, June, 1862. 

Dublin Medical Press. March, April, May, 1862. 

The Medical Critic and Psychological Journal. Edited by Forbes Wjnslow, 
M. D., D. C, L. Oxon. April, 1862. 

London Medical Review. March, April, 1862. 

The Madras Quarterly Journal of Medical Science. January, 1862. 

The Medical Record of Australia. Edited by Dr. Reeves, January, 1862. 

The British American Journal. Edited by Archibald Hall, M. D. March, 
May, 1862. 

Boston Medical and Surgical Journal. Edited by F. E. Oliver, M. D., and 
S. L. Abbot, M. D. April, May, June, 1862. 
American Medical Times. April, May, June, 1862. 

The Cincinnati Lancet and Observer. Edited by Ed. B. Stevens, M. D., and 
J. A. Murphy, M. D. April, June, 1862. 

Ohio Medical and Surgical Journal. Edited by the Professors of Starling 
Medical College. March, May, 1862. 

The American Journal of Insanity. Edited by the Medical Officers of the 
New York State Lunatic Asylum. April, 1862. 

The American Journal of Science and Arts. Edited by Professors B. Silli- 
MAN, B. SiLLiMAN, Jr., and Jas. D. Dana. May, 1862. 

The Chicago Medical Journal. Edited by D. Brainard, M. D., and J. A. 
Allen, M. D. April, May, June, 1862. 

The Chicago Medical Examiner. Edited by N. S. Davis, M. D., and F. W. 
Reilly, M. D. March, April, May, 1862. 

Buffalo Medical and Surgical Journal and Reporter. Edited by Julius F. 
Miner, M. D. April, May, June, 1862. 

American Medical Monthly. Edited by J. H. Douglas, M. D. April, May, 
June, 1862. 

The Pacific Medical and Surgical Journal. Edited by James Blake, M. D. 
February, March, April, May, 1862. 

The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D., 
and J. A. Thacker, M. D. March, April, May, 1862. 

San Francisco Medical Press. Edited by E. S. Cooper, A. M., M. D. April, 
1862. 



10 



TO READERS AND CORRESPONDENTS. 



The American Journal of Ophthalmology. Yol. I., No. 1. Julius Hom- 
BERGER, M.D., editor and proprietor. New York. July, 1862. 

American J ournal of Pharmacy. Published by authority of the Philadelphia 
College of Pharmacy. Edited by Wm. Proctor, Jr., Professor of Pharmacy in 
Philadelphia College of Pharmacy. May, 1862. 

The American Druggists' Circular and Chemical Gazette. April, May, June, 
1862. 

The Dental Cosmos. Edited by J. D. White, M.D., J. H. McQuillan, D. 
D. S., and Geo. J. Ziegler, M.D. April, May, 1862. 



Communications intended for publication, and Books for Review, should be sent, 
free of expense, directed, to Isaac Hays, M. D., Editor of the American Journal of the 
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed 
as above, and (carriage paid) under cover, to Messrs. Triibner & Co., Booksellers, 
No. 60 Paternoster Row, London, E. C. ; or M. Hector Bossange, Lib. quai Voltaire, 
No. 11, Paris, will reach us safely and without delay. We particularly request 
the attention of our foreign correspondents to the above, as we are often subjected 
to unnecessary expense for postage and carriage. 

Private communications to the Editor may be addressed to his residence, 1525 
Locust Street. 

All remittances of money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Blanchard & Lea. 

The advertisement-sheet belongs to the business department of the Journal, 
and all communications for it should be made to the publishers. 

To secure insertion, all advertisements should be received by the 20th of the 
previous month. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. LXXXYII. NEW SERIES. 
JULY, 1862. 



ORIGINAL COMMUNICATIONS. 

MEMOIRS AND CASES. 

ART. PAGE 

L Remarks on Fungi, with an account of Experiments showing the Influ- 
ence of the Fungi of Wheat Straw on the Human System ; and some 
Observations which point to them as the Probable Source of " Camp 
Measles," and perhaps of Measles generally. By J. H. Salisbury, M. D., 
of Newark, Ohio. (With a plate containing twenty figures.) . . 17 

II. On Cardiac Murmurs. By Austin Flint, M. D., Professor of the Prin- 
ciples and Practice of Medicine iia the Belle vue Hospital Medical College, 
New York, and in the Long Island College Hospital 29 

III. On Smallpox, and the Means of Protection against it. By S. Henry 
Dickson, M. D., Professor of the Practice of Medicine in Jefferson Medi- 
cal College, Philadelphia. 54 

lY. Amaurosis and other Disorders of the Eye, resulting from Injury of 
the Terminal Branches of the Fifth Pair of Nerves. By Frederic D. 
Lente, M. D., of Cold Spring, New York. 70 

Y. On Burns. By John Ashhurst, Jr., M.D., late Senior Resident Sur- 
geon to the Pennsylvania Hospital. 82 

YI. On the Employment of India-rubber in obtaining Continuous Exten- 
sion in the Treatment of Fractures of the Femur. By John H. Packard, 
M. D., of Philadelphia. (With a wood-cut.) 88 

YII. On the Epidemic Relationship of Zymotic Diseases. By E. P. Chris- 
tian, A. M., M. D., Wyandotte, Michigan 91 

YIIL Description of a Pseudencephalic Monster. (Genus 11, Thlipsence- 
phalus, Isidore Geoff. St. Hilaire.) By Christopher Johnston, M. D., 
Baltimore. (With three wood-cuts.) 96 

IX. Cases treated at the Medical Missionary Society's Hospital at Canton, 
China. By John G. Kerr, M. D. (Communicated by Professor S. D. 
Gross, M.D.) . . 99 

X. Case of Puerperal Uraemia. By Y. J. Fourgeaud, M. D. of San Fran- 
cisco, California 103 

TRANSACTIONS OF SOCIETIES. 

XL Summary of the Proceedings of the Pathological Society of Phila- 
delphia 105 

Singular Lesion of the Urinary Bladder. By Dr. Packard. . . 105 
Compound Comminuted Fracture of the Skull, and Fracture of Ribs. 

By Dr. Ashhurst 106 

Gangrene of the Lung. By Dr. Leet 107 



12 



CONTENTS. 



ART. PAGE 

Mammary Carcinoma. By Dr. Ashhurst 107 

Eupture of the Urethra. By Dr. Lee 108 

Gunshot Wound of Femur and Pubis. By Dr. Packard. . . 109 

Deformity of Legs. By Dr. Lee 110 

Incarcerated Hernia. By Dr. Lee Ill 

Compound Comminuted Fracture of Thigh; Fracture of Scapula 

and of Ribs, with Scalp Wounds and Effusion on Brain. By Dr. 

Ashhurst ' . 112 

Compound Fracture of Sacrum. By Dr. Lee. .... 113 
Compound Comminuted Fracture of Skull ; Fracture of Pelvis and 

Rupture of Bladder. By Dr. Lee 114 

Ruptured Peritoneum. By Dr. Ashhurst 114 

Comminuted Fracture of Pelvis, Fracture of Thigh, &c. By Dr. 

Lee 115 

Tubercle of Kidney. By Dr. Ashhurst 116 

Metastatic Abscesses. By Dr. Packard. 117 

Deficiency in the number of Ribs. By Dr. Packard. . . . 118 



REVIEWS. 

XII. Theories of Life and Organization. 

1. Recherches Physiologiques sur la Yie et la Mort. Par F. X. Bichat. 
Nouvelle Edition, precedee d'une Notice sur la vie et les Travaux de 
Bichat et suivie de Notes par le Docteur Cerise. Paris : Yictor Masson 
et Fils, 1862. 8vo. pp. 382. 

2. De la Yie et de I'lntelligence. Par P. Flourens, Membre de I'Academie 
Francaise et Secretaire perpetual de I'Academie des Sciences (Institut 
de France), etc. Paris : Garnier Freres, 1858. 8vo. pp. 161. 

3. La Medecine Nouvelle bas6e sur des Principes de Physique et de Chimie 
transcendantes et sur des Experiences capitales qui font voir mecanique- 
ment I'origine du Principe de la Yie. Par L. Lucas. Paris : F. Savy, 
1861. Tome ler. 8vo. pp. 504. 

4. La Yie dans I'Homme; Existence, Fonction, Nature, Condition pr6- 
sente, Forme, Origine et Destinee future du Principe de la Yie ; Esquisse 
Historique de TAnimisme. Par J. Tissot. Paris : Yictor Masson et 
Fils, 1861. 8vo. 

5. La Yie dans I'Homme ; ses Manifestations diverses, leurs Rapports, leurs 
Conditions Organiques. Par J. Tissot. Paris : Y. Masson et Fils, 1861. 
8vo. pp. 614. 

6. Discours sur le Yitalisme et I'Organicisme et sur les Rapports des Sci- 
ences Physiques en General avec la Medecine : Discours prononce a 
I'Academie Imperiale de Medecine, 17 Juillet, 1860. Par M. le Profes- 
seur Bouillaud. Paris, 1860. 8vo. pp. 75 119 

XIII. Epilepsy : its Symptoms, Treatment, and Relation to other Chronic 
Convulsive Diseases. By J. Russell Reynolds, M. D., Lond. London, 
1861. 8vo. pp. 360. 

Epileptic and other Convulsive Affections of the Nervous System, their 
Pathology and Treatment. By Charles Bland Radcliffe, M. D. Third 
edition. London, 1861. 12mo. pp. 312 134 

XIY. Traite de Chirurgie Navale. Par Louis Saurel, Chirurgien de la 
Marine, Professor agreg6 a la Faculty de Medecine de Montpelier, Cor- 
respondant de la Societe de Chirurgie de Paris ; Suivi d'un resume de 
lecons sur la service chirurgical de la flotte. Par le Docteur J. Rochard, 
Chirurgien en chef de la Marine, Professor k I'Ecole de Medecine Navale 
du port de Brest, Officier de la Legion d'honneur. Illustr6 de 186 
planches intercalees dans le texte. 8vo. pp. 592 + 104. J. B. Ballifere 
et Fils. Paris, 1861. 

Treatise on Naval Surgery. By Louis Saurel, Surgeon of the Navy, &c., 
followed by a summary of lectures on the surgical service of the fleet. 
By Doctor J. Rochard, Surgeon in Chief of the Navy, &c. Paris, 1861. 149 



CONTENTS. 



13 



ART. PAGE 

XV. Lectures on the Germs and Yestiges of Disease, and on the Preven- 
tion of the Invasion and Fatality of Disease by Periodical Examinations. 
Delivered at the Royal Infirmary for Diseases of the Chest. By Horace 
Dobell, M. D., &c. &c., Physician to the Infirmary. London, 1861. 8vo. 
pp. 198 157 



BIBLIOGRAPHICAL NOTICES. 

XYI. Reports of American Institutions for the Insane. 

1. Of the Butler Hospital, for the year 1860. 

2. Of the New Jersey State Hospital, for the year 1860. 

3. Of the Western Asylum of Virginia, for the fiscal year 1859-60. 

4. Of the State Asylum of South Carolina, for the year 1860. 

5. Of the Northern Ohio Asylum, for the fiscal year 1859-60. 

6. Of the Hamilton County (Ohio) Asylum, for the fiscal year 1858-59. 

7. Of the Asylum of California, for the year 1858. 

8. Of the Wisconsin State Hospital, for the year 1860 165 

XVII. Lectures on the Diagnosis and Treatment of the Principal Forms 
of Paralysis of the Lower Extremities. By E. Brown-S6quard, M. D., 
F. R. S., Fellow of the Royal College of Physicians of London, Hon. 
Fellow of the Faculty of Physicians and Surgeons of Glasgow, Laureate 
of the Institute of France (Academy of Sciences), etc. etc. 8vo. pp. 118. 

J. B. Lippincott & Co. : Philadelphia, 1861. . . . . . .175 

XVIII. Surgical Tracts. 

1. Amputation of the Cervix Uteri. By J. Marion Sims, M. D. Extracted 
from the Transactions of the State of New York, 1861. New York, 1861. 
8vo. pp. 16. 

2. Extension and Counter-extension in the Treatment of Fractures of the 
Long Bones; with a Description of an Apparatus especially designed for 
Compound Fractures. By Joseph H. Vedder, A. M., M. D. New York, 
1862. 8vo. pp. 23. 

3. A Description of the newly-invented Elastic Tourniquet, for the Use of 
Armies and Employment in Civil Life, its Uses and Applications, with 
Remarks on the Different Methods of Arresting Hemorrhage from Gun- 
shot and other Wounds. New York, 1862; 8vo. pp. 31. 

4. On Intestinal Obstruction by the Solitary Band. Being a paper read at 
a meeting of the Medical Society of London, March 25th, 1861, and re- 
printed from their Transactions. By John Gay, F. R. C. S., &c. London, 
1861. Printed for private circulation. 8vo. pp. 16 179 

XIX. Handbook of S.urgical Operations. By Stephen Smith, M.D., Surgeon 

to Bellevue Hospital. New York : Bailliere Brothers, 1862. 12mo.pp.279. 181 
■ XX. Transactions of the Obstetrical Society of London. Vol. III. 8vo. 
pp.480.. London, 1862 182 

XXI. Public Health in Relation to Air and Water. By W. T. Gairdner, 
M. D., Fellow of the Royal College of Physicians, Edinburgh ; Physi-cian 
to the Royal Infirmary, and Lecturer on the Practice of Medicine. 12mo. 

' pp. 369. Edinburgh, 1862 192 

XXII. The Ambulance Surgeon, or Practical Observations on Gunshot 
Wounds. By P. L. Appia, M. D., Fellow of the Royal Society of Naples, 
&c. Edited by T. W. Nunn, Assistant Surgeon to the Middlesex Hos- 
pital, and A. M. Edwards, F. R. S. E., Lecturer on Surgery in the Edin- 
burgh Medical School. Edinburgh, 1862. 12mo. pp. 266. . . .200 

XXIII. Experiments and Observations upon the Circulation in the Snap- 
ping Turtle, Chelonura Serpentina, with especial Reference to the Pressure 
of the Blood in the Arteries and Veins. By S. Wier Mitchell, M. D., 
Lecturer on Physiology. Philadelphia, 1862. 4to. pp. 14. . . . 201 

XXIV. A Manual of Medical Diagnosis : being an Analysis of the Signs 
and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., As- 
sistant Physician to St. George's Hospital, &c. &c. Second American, 
from the second and revised London edition. Philadelphia : Blanchard 

& Lea, 1862. 8vo. pp. 451 202 



14 



CONTENTS. 



QUAKTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOYERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIOENCE. 

Anatomy and Physiology. 



PAGE 

1. On the Tactile Sensibility of tlie 
Hand. By Dr. Ballard. . . 203 

2. Yalves of tlie Yeins of tlie Ex- 
tremities. By M. Verneuil. . 204 



PAGE 

3. Marriages of Consanguinity and 
Deaf-Dumbness. By M. Boudin. 205 

4. Marriages of Consanguinity and 
their Influence on Offspring. By 
Dr. Mitchell 205 



Materia Medica and Pharmacy. 



5. Action of Alcohol as an Ali- 
ment in Disease. By Dr. F. E. 
Anstie 208 

6. Therapeutic Properties of the 
Peroxide of Hydrogen. By Dr. 
Eichardson 209 

7. Podophylliu. By Dr. Gardner. 210 

8. Therapeutical Properties of 
Malt. By M. Fremy. . .212 

9. Substitution of Daturia for 
Atropia. By M. Jobert. . . 212 

10. Antiseptic Properties of Am- 
monia. By Dr. Eichardson. . 212 



11. Inhalation of Pulverized Fluids. 

By M. Poggiale. . . .214 

12. Administration of Cod-Liver 
and other Oils, By Dr. Alex- 
ander Wallace. . . . 214 

13. New Preparation from Chloro- 
form. By Dr. Thomas Skinner. 215 

14. Vesicating Collodion. By Mr. 

C. E. C. Tichborne. . . .216 

15. Solid Creasote. By M. Stanis- 
laus Martin 217 

16. Inefficiency of Hyoscyamus as 
usually prescribed. By M. Do- 
novan. . . . . . 218 



Medical Pathology and Therapeutics, and Practical Medicine. 



17. On the Exhibition of Food in 
Typhoid Fever. By M. Herard. 218 

18. Quinine as a Prophylactic of 
Fever. By Dr. Smart. . . 221 

19. Clinical Inquiry into the Use 
of Iron in Pulmonary Consump- 
tion. By Dr. James Jones. . 221 

20. Chlorate of Potassa in Phthi- 
sis. By Dr. E. P. Cotton. . 223 

21. Delirium Tremens treated by 
Large Doses of Digitalis. By 
Mr. Hester 224 

22. Treatment of Pleurisy. ByM. 
Trousseau. . . . - . 226 

23. Pneumonia in Infants. By M. 
Barthez. . . . . . 226 

24. Treatment of Cancrum Oris. 
By Dr. Alexander Keiller. . 227 ! 



25. Pathology and Treatment of 
Jaundice. By Dr. Geo. Harley. 230 

26. Treatment of Dysentery. By 
Dr. Smart 231 

27. Subnitrate of Bismuth in Di- 
arrhoea and Chronic Dysenterv. 
By Dr. Gaubert. . . 231 

28. Saccharine Treatment of Dia- 
betes Mellitus. By John Hughes, 
M.D 232 

29. Chorea treated by Sulphate of 
Aniline. By Dr. Morell Mack- 
enzie. 235 

30. Individual Eemedies in Epi- 
lepsy. By Dr. Anstie. . .235 

31. Statistical Inquiry into the 
Prevalence of Numerous Condi- 

! tions affecting the Constitution 



CONTENTS. 



15 



in one thousand Phthisical Pa- 
tients when in Health. Bv Dr. 
Edward Smith. . . . 236 

32. Brass Founders' Ague; Dis- 
ease produced br Fumes of Zinc. 

By Dr. Greenhow. . . .238 

33. Sudden Death from Emboli. 

By M. Briquet. . . .239 

34. Case of Syphilitic Disease ap- 
pearing in two Healthy Children 



PAGE 

after Vaccination from a Syphi- 
litic Child. ByDr.N. J.Haydon. 239 

35. Yalue of ^gophony as a Sign 

of Pleurisy. By Prof. Landouzy. 240 

36. Tsenia Solium. ByM.Mauche. 240 

37. On the Probabilities of the 
Duration of Life in the Apo- 
plectic and the Phthisical. Dr. 
Bruckner 241 



SuKGiCAL Pathology axd Theeapeutics, axd OPERATiyE Surgery. 



38. Treatment of Burns. By Prof. 
Eoser. . . . \ .242 

39. Traumatic Tetanus cured by 
Chloride of Barium. By Dr. 
Gnecchi 243 

40. The Influence upon the Growth 
of the Bones of Paralysis, Dis- 
ease of the Joints, Disease of the 
Epiphysial Lines, Excision of 
the Knee, Pickets, and some 
other Morbid Conditions. By 
Dr. G. M. Humphry. . . 244 

41. Ligature of the Common Ca- 
rotid. By Dr. Redfern Dayis. . 245 

42. Operations for the Cure of 
Varicocele and Varicose Veins. . 
By Dr. M. H. Collis. . . 246 

43. Stability of the Cure of Va- 
rices. By M. Blot. . . .247 

44. True Anchylosis of the Left 
Hip -Joint, from Rheumatism; 
the limb at a right angle to the 
body, and abducted; excision of 
a wedge-shaped piece of the 
femur; cure. By Dr. H. V. 
Berend 247 

45. Dislocation of the Ulna for- 
wards without Fracture of the 
Olecranon. By M. Caussin. . 248 



46. Dislocation of the Foot For- 
wards. By Dr. Demarquay. . 248 

47. Fracture of a Rib produced by 
a Sneeze. By Dr. D. F. Cas- 
tella 249 

48. Transverse Fracture of the 
Patella. _ By Mr. Holthouse. . 249 

49. Statistics of Amputations at 
the Hospitals of Paris. By Dr. 
Ulysses Trelat. . ." .250 

50. Perforating Gunshot "Wound 
through the Thickness of the 
Lung; Recoyery. ByDr.Voods. 250 

51. Difficulties in the Treatment 
of Umbilical Hernia. By M. 
Huguier " . 252 

52. Ether and Belladonna in Stran- 
gulated Hernia. By Dr. Burk- 
hardt. . . ^ . .253 

53. Camphorated Chloroform as a 
Local Anaesthetic in Extirpation 
of the Toe Nail. By M. Mar- 
tenot de Cordoux. . . . 253 

54. Congenital Inyersion of the 
Bladder; Cure. By J. Lowe, 

M. D 253 

55. The Cochin China Ulcer. By 

M. Pochard. . . . \ 254 



Ophthalmology. 



56. Frequent Eyacuation of the 
Aqueous Humour as a Means 
of Causing the Absorption of 
Cataract. By Prof. Sperino. . 

57. Hereditary Amaurosis. By 
Mr. Sedgwick 

58. Amaurosis cured by Eyacua- 
tion of the Aqueous Humour. . 

59. Retinitis Leuksemica. By Dr. 
Liebreich. .... 

60. Embolism of the Arteria Cen- 
tralis Retinte. By Dr. Liebreich. 

61. Loss of an Eye from the Bite 



of a Leech. By Professor Von 

Graefe 259 

62. Piece of Stone Imbedded for 

255 Seyen Months in the Cornea. 

By Dr. Wm. Hutchinson. . 259 

256 63. Rectification of Diyergent 

Strabismus by the Methodical 

257 Use of Prismatic Glasses. By 
Dr. Giraud-Teulon. . . \ 259 

258 64. Hemorrhage into the Anterior 
I Chamber of the Eye. supplemen- 

258 i tary to the Menstrual Flux. By 
i M. Guepin. . . . 261 



16 



CONTENTS. 



Midwifery. 



. 261 



263 



PAGE 

65. Meclianism of Labour. By Dr. 
Halahan. . 

66. Induction of Premature La- 
bour in Cases of Constitutional 
Affections. By Dr. Keiller. 

67. Internal Surface of the Uterus 
after Delivery. By Dr. J. Mat- 
thews Duncan 

68. Unsuspected Pregnancy and 
Labour. By Dr. H. Tanner. 

69. Twins; One Dead at Six 
Months ; Both Eetained until 
full Term. By Dr. Flecken. . 266 

70. Diagnosis of the Sex of the 
Foetus. By Dr. Steinbach. . 266 

71. Epidemic of Puerperal Phleg- 



265 



265 



PAGE 

monous Erysipelas at Stockholm. 
By Prof. Retzius. . . .269 

72. Treatment of Peritonitis by the 
Continued Application of Cold 

to the Abdomen. By M. B6hier. 270 

73. Broncho-Pneumonia of Lying- 
in Women. By Dr. Barnes. . 271 

74. Ovarian Tumour cured by Tap- 



pmr 



and followed by Two 



Pregnancies. By M. L. R. 
Cooke 

75. Intra-Uterine Convulsions. By 
Dr. James A. Sidey. 

76. Pathogeny of Retro-Uterine 
Hsematocele. By Prof. Braun. 



271 



272 



273 



Medical Jurisprudence and Toxicology. 



77. Additional Experiments on the 
Poisonous Effects of Coal Gas 
upon the Animal System. By 

Dr. C. J. B. Aldis. . . .274 

78. Connection between Poisoning 
by Phosphorus and Fatty De- 



generation of the Liver. By 
Dr. Lewin. . . . .275 

79. Poisoning by Aniline and by 
Nitro-Benzol 275 

80. New Mode of Detecting Minute 
Traces of Morphia. By M. Le- 
fort 276 



AMERICAN INTELLIGENCE. 



Original Communications. 



Case of Opium Poisoning in which 
Belladonna was successfully used 
as an Antidote. By W. S. Dun- 
can, M. D 277 

Clover-Hay Tea in Hooping-Cough. 
By Dr. Condie 278 



Prolonged Abstinence. By Geo. 
Ord, Esq 278 

Case of Monstrosity. By L. W. 
Baker, M.D 278 

Syrup of Triticum Repens in Irri- 
table Conditions of the Urinary 
Bladder. By the Editor. . 279 



Domestic Summary. 



Case of Poisoning by Laudanum — 
Belladonna used as an Antidote. 
By Dr. James Blake. . . 280 

On the Non-Shortening of the Su- 
pra and Infra-Yaginal Portion 
of the Cervix Uteri. By Dr. 
Isaac E. Taylor. . . .281 

Body Transfixed by a Bayonet ; 
Recovery. By Dr. B. J. D. Irwin. 283 

Inversion of the Uterus of Thirteen 
Years' Standing reduced by a 
Novel Method. By Dr. E, Noeg- 
gerath. 283 



Nitric Acid in Hooping Cough. 
By Dr. S. W. Noble. . . 284 

Seeds of the Cucurbita Pepo, or 
Pumpkin, in Taenia. By Dr. G. 
R. Patton 284 

Staphyloma of Cornea ; Iridecto- 
my ; Suppuration of Globe. By 
Dr. Henry D. Noyes. . . 284 

Polypus of the Ear successfully 
destroyed by the Persulphate of 
Iron. By Dr. E. L. Holmes. . 285- 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 186 2. 



Art. I. — Remarks on Fungi, ivifJi an account of Experiments sJioicing 
the Influence of the Fungi of Wheat Straw on the Human System; and 
some Observations ichich point to them as the P7vbable Source of Camp 
Measles,''^ and perhaps of Measles generally. By J. H. Salisbury, M.D., 
of Newark, Ohio. (With a plate containing twenty figures.) 

The fungi belong to the lowest types of vegetable existence. Unlike the 
higher orders of plants, they are developed almost entirely in darkness (not 
being able to decompose carbonic acid under the influence of light), and they 
depend upon decaying or decomposing organic matter for the materials of 
their growth. They differ from flowering plants in their chemical influence 
upon the air. Like animals, they absorb oxygen and give out carbonic 
acid. Decay is an essential condition to their development. Besides 
organic decomposition, a certain degree of heat and moisture must exist. 
These three conditions are requisite, to excite their vegetative activity — 
but in very different degrees in the different families. There is another 
peculiarity ; their cells contain a large percentage of nitrogenized matter, 
making their composition more analogous to animal matter, than to the 
higher orders of plants. Their growth and maturity are usually rapid — 
requiring often but a few hours — and with almost equal rapidity they 
decay. The odours they emit in decay are more like those of putrescent 
animal than of vegetable matter. There are exceptions to this, however, 
in those families where their textures are of an almost woody firmness and 
of a slow growth, as in many of the Polypori and Boliti. 

The fungi are variously distributed among organized nature; each species 
growing only upon such bodies (even though the temperature and moisture 
be rightly adapted) as will furnish to it the materials from which it can 
make the proximate products that are peculiar to it. For instance, the 
No. LXXXYII.— July 1862. 2 



18 Salisbury, Effects of Fungi on Human System. [July 

gory dew and red snow (Protococcus nivalis) form invariably a peculiar 
red secretion, to which they owe their colour; and they will grow only 
where they can obtain the elements to form this red matter. The yeast 
plant {Peyiicillium) invariably forms an albuminous secretion, and it will 
vegetate only in bodies which can supply the materials for this substance. 
From this it would appear that peculiar states and combinations of organ- 
ized matter control mainly the developmental distribution of parasitic fungi. 
The spores planted in their proper soil, only demand in addition a certain 
amount of moisture and degree of temperature — these present, they rapidly 
develop. 

Those Fungi known by the common name of mould, mildew, smut, &c., 
attach themselves to and are developed from living tissues as well as from 
dead organic matter ; yet in both cases they depend alike upon decay for 
their development. 

In plants we have common examples of this in the Uredo, which attacks 
tlie-maire plant; the Secali, which attacks the rye plant ; the Fuccinea, 
which attacks the rose bush ; the Botrytis infestans, which causes the 
potatoe.rot; the Merulius lacrymans and Folyporus destructor, which 
cause dry rot in timber ; the Sphderia morhosa, which attacks plum trees ; 
the Oidium, which produces decay in fruit ; the Fenicillium and Asper- 
gillus, which attack bread and cheese ; and the yeast and vinegar plants, 
which are submerged stems or mycelia of the Fenicillium. The savin or 
juniper tree is attacked by a peculiar genus — Fodisoma — which bursts from 
the bark and swells under the influence of moisture to a gelatinous mass ; 
and the black irregular scars on apples are produced by the Spilocena 
fructigena. 

Others attack the housekeepers' preserved fruits, paste, mustard, and even 
clothing. Others the farmers' grain and grass ; the vintigers' grapes ; and 
the gardeners' vines, vegetables, and flowers. Scarcely any vegetable pro- 
duction, either living or dead, escapes the ravages of these parasites. 

Animals also have their parasitic fungi. The disease (in Italy and the 
South of France) termed Muscadine, which sometimes attacks the cater- 
pillars of the silkworm in large numbers, just when they are about to enter 
the chrysalis state, has been ascertained to be due to the growth — within 
their bodies — of a minute fungus {Botrytis hassiana) nearly resembling 
the common mould. 

It is capable of being communicated from one individual to another. It 
spreads in the fatty tissue beneath the skin, occasioning its destruction. 
The fungus spreads by the extension of its own stems and branches, and by 
the production of numerous sporules, which in their turn vegetate, and 
finally produce the death of the worm. 

The flies found adhering to our windows are destroyed by a mould 
(Sporendonema muscae) which produces the little white rings between the 
abdominal segments and discharges its spores upon the glass around like a 



1862.] Salisbury, Effects of Fungi on Human System. 19 

little cloud. In the West Indies, it is not at all uncommon to see indivi- 
duals of the species Polistes (a wasp-like insect) flying about with plants, 
their own length, projecting from some part of the body. In time this 
growth spreads through the whole body, causing death ; after which the 
plants grow with much more luxuriance from the dead body than they 
formerly had from the living. 

A similar growth {Cordyceps Robertsii) takes place in the bodies of 
certain caterpillars in New Zealand, Australia, and China. Some of our 
American caterpillars are destroyed by the Cordyceps militaris. The 
Onygena exigua attacks the hoofs of the horse, and the hoofs and horns 
of cattle. (The Isariafelina is found in the feces of cats deposited in dark 
and obscure places.) 

In certain diseased conditions of the cutaneous surface — in man — named 
Porrigo favosa and Sycosis menti, a considerable development of fungous 
vegetation takes place ; and the same has been discovered to be true of the 
white patches {Aplithse) on the lining membrane of the mouth in children, 
which are known as thrush. In all these cases, however, a certain morbid 
condition of the animal fluids must exist in order that the germs of the 
fungus may develop themselves ; so that the condition, rather than the 
presence of the fungus must be looked upon as the essence of the disease.^ 
The individual cells and spores of the Fungi are microscopic, and so light 
that they are suspended in and borne about by the air. They are so minute 
that they permeate alike the tissues of animals and plants. Whenever it 
happens that the spores enter matter that is suited to their sustenance, and 
the proper amount of heat and moisture are present, they rapidly develop. 
It would be very strange if very many abnormal conditions of living tissues 
were not produced by this insidious vegetation. The plants being mostly 
microscopic, and requiring often but a few hours for their development and 
decay, renders their discovery one fraught with far greater difficulty than 
would at first be supposed. When no development of the spores takes 
. place in the tissues, no doubt in many instances they exercise a deleterious 
influence by their presence alone, as many of the larger and better known 
fungi have been ascertained to possess peculiar poisonous properties, which, 
in their action on the human system, resemble much in their depressing 
effects the animal poisons. 

With these preliminary remarks we enter upon — 
Some observations connected with measles and the fungi ofioheat straiu. 

Hon. J. Dille, of Newark, Ohio, came to my office on the evening of the 
9th of December last, and stated that he was just recovering from what he 
believed to be an attack of measles. It was his opinion he had caught them 
from pitching straw from an old stack. He stated that on December 4th 
he pitched from an old stack a load of straw, and unloaded it in his stable. 

' Carpenter's General and Comparative Physiology. 



20 Salisbury, Effects of Fungi on Human System. [July 

Portions of the stack had become partially decayed, and was already steam- 
ing with the heat of incipient decomposition. In pitching over and picking 
out the best straw the air became filled with a fine dust, which he freely 
inhaled. The dust tasted and had the odour of old straw. This took 
place during the forenoon. His throat soon began to feel dry and irritated. 
When he returned to dinner, he could still taste and smell the old straw. 
This taste and smell he could not get rid of. During the following night 
he awoke with a very sore throat, which became much worse by morning. 
After getting up and dressing he was taken with a severe chill, with pains 
in the head and back, and felt so sick and prostrated that he was compelled 
to return to bed again, where he remained through the day. The chill was 
followed by a high fever and severe pains in the head, so much so that a 
portion of the time he was delirious. He felt a heavy congested feeJing 
about the chest, his throat and fauces were swollen and inflamed, with severe 
catarrhal symptoms. An eruption like that of measles appeared on his face 
and neck, and the old straiv taste still continued. His fever continued high 
through the following (Thursday) night, with severe pains in the head. 

Friday, December 6th, he felt much better, and was able to be up around 
the house. The fever and catarrhal symptoms had partially subsided. His 
eyes were sensitive, watery, and inflamed. 

Saturday, December tth, felt much better. The eruption had passed 
downward over the whole body, and had begun to disappear from the face. 
He rapidly recovered, so that on Monday, December 9th, he was moving 
about the streets. In the evening of the 9th he called at my office. His 
eyes were still reel, inflamed, and sensitive ; throat sore, dry, and voice 
hoarse, and had a heavy congested feeling still about the chest. The 
blotches on his face could be faintly distinguished. He stated that he could 
still taste the old straw in his throat. 

Measles at Gamp Sherman. — At the military camp — Camp Sherman — 
Newark, Ohio, the measles first appeared on Dec. 4th, the same day that 
Mr. Dille exposed himself to the straw dust. From Nov. 23d to 30th, 
the weather was cool, damp, with considerable sleety rain and snow. 
During this time (there being between six and seven hundred men in camp), 
many of the tents were furnished with ticks, which were filled with straw 
for the men to sleep on. In the centre of each tent was a fire, built in a 
hole in the ground, from which the smoke was led off by an underground 
flue, extending to the outside of the tent. The straw ticks were arranged 
around the fire, several in a tent, and each tick accommodated two men. 
On Dec. 1st, the weather became colder and snow fell to the depth of about 
an inch. On the 2d — which was quite warm — this melted and wet the 
soil and dampened the straw ticks. Dec. 4th, the measles made their first 
appearance in Camp Sherman. The men came from different parts of the 
county, and no one knew that he had been exposed to the disease. Some 
had been in camp two weeks, and no one supposed to have that disease 
had visited the camp. Subsequent inquiries have failed to discover any 
one who brought them there, or to account for their appearance from the 
contagion of the disease. On the first day (Dec. 4th) there were eight 
cases, and within a week after there were forty. The disease then disap- 



1862.] Salisbury, Effects of Fungi on Human System. 21 



peared for 10 or 12 days from its first appearance. Between the 14tli and 
16tli the disease again made its appearance, and within a few days there 
were between forty and fifty cases more, when the disease ceased altogether. 
These last cases, occurring so near the usual time at which the disease ordi- 
narily makes its appearance after exposure, renders it probable that they 
were communicated from the first cases.^ 

On the 3d of Dec. it became warm and pleasant as growing weather in 
spring — and continued warm and delightful till Dec. 10th. On the 11th 
and 12th it was cold and freezing. The 13th and 14th were cool. From 
the 15th to the 21st the weather was warm and pleasant. 

The following is the statement of Mr. S. — "In JSTovember, 1842, I 
returned home from school on a Friday. My father had the threshers, with 
a machine, threshing wheat. The wheat had been stowed away in the 
mow and in a couple of stacks outside the barn. It had undergone a slight 
heating, and some of the straw was mouldy. In threshing, the barn was 
filled with a fine dust, which tasted and smelled of old straw. I was on 
the straw stack all Friday afternoon and the whole of Saturday. About 
4 P.M., Saturday, I became very chilly; throat and fauces became sore 
and swollen ; a tightness and congested feeling about the chest ; eyes in- 
flamed and sensitive ; and severe pains through the head and shoulders 
with a feeling of weariness. Following the chill, came on a high fever 
with increased pains and throbbing in the head and severe catarrhal symp- 
toms. I do not remember of ever passing a more disagreeable night. The 
next day (Sunday) had a high fever, with severe pains in head, back and 
limbs ; eyes swollen and sensitive, and considerable thin mucous secretion 
from the nose and fauces. Towards evening a few blotches made their 
appearance on my face. The follov^ang day (Monday) I felt rather better ; 
the fever and catarrhal symptoms had partially subsided, and my face and 
neck were completely covered with blotches. My father immediately re- 
marked that I had measles. This surprised us all, as I had not been exposed 
to the disease, there being none in the town where I was attending school, 
or in the vicinity. In the coarse of a couple of days, my Avhole body and 
limbs were covered with the eruption. The disease passed off' like a case 
of ordinary measles, leaving no bad effects, save inflammation of the mucous 
membrane of the eyes. This I did not get rid of till the warm weather of 
the following spring. In from seven to fourteen days after the eruption 
commenced in my case, all my brothers and sisters (seven in number) were 
in bed with the genuine measles. My eldest brother attended school with 
me, and returned home when I did. These were the only cases of measles 
anywhere in the vicinity during that fall and winter. In my attack the 
disease commenced with much greater violence than in either of the others. 
The fever ran higher and there was greater disturbance about the head, 
chest, and throat." 

Bearing upon this may be mentioned the circumstance that in almost 
every instance, where our soldiers have gone into camp; in a short time 
after — the disease — called camj) measles, has made its appearance, without 

' For these facts I am indebted to Hon. J. Dille, and tlie Assistant Surgeon Dr. 
James Hood. 



22 



Salisbury, Effects of Fungi on Human System. [July 



any previous exposure — so far as known — to the measles. It should also 
be stated that their beds have been usually straw. 

At the monthly meeting of the " Farmer^s Club,^^ near Newark, Ohio, 
last month, several of the farmers stated to Mr. Dille, that it was quite 
common, after threshing wheat, for persons who had been exposed much 
to the dust, to be taken with severe chills; followed by a high fever, catar- 
rhal symptoms and an eruption on the face. None of them could state, 
that any one had ever had the attack twice ; nor whether they had known 
any cases to follow the threshing of any other kind of grain than wheat. 

It is well known among swine growers, that when they bed their hogs 
in straw, they are affected with an eruption in the throat, fauces and roof 
of mouth, accompanied with coughing. 

Microscopical Examination of the Fungi of Wheat and Rye Straw. — 
With these observations before us, we deemed the subject one worthy of a 
further and more careful examination ; an examination which would afford 
something more positive. With this view, the fungous growths of wheat 
straw, and the dust rising from it when disturbed, were carefully examined 
under the microscope. The straw used for this purpose was taken from 
the beds at Camp Sherman, from Mr. Dille's stable, and from stacks in the 
vicinity of Newark. The accompanying drawings (see Plate, Figs. 1 to 14) 
represent the plants found — a description of which is given further on. 

We then took clean bright wheat straw — free from fungi — packed it 
firmly into a box about one foot square and high, wet it with about four 
ounces of cold well-water, pressed on and secured the lid, and set the box 
near the stove in the ofiBce, where the temperature ranged from 60° to Y5° 
Fahr. Twenty-four hours afterwards I opened the box, and found the straw 
in the centre of the box heated and covered with a short white mould. 
As the straw was stirred, a fine dust of spores and cells were disengaged, 
and rose in the air, which, when inhaled, had the odour and taste of old 
straw. Examined the fungi under the microscope. The plants were in 
all stages of development, from those just starting to those with matured 
sporangia. 

Again the straw was moistened, the lid secured as before, and left for 
forty-eight hours. The box was then opened. Found the mould had ex- 
tended wider through the mass and more completely covered the straw. 
Submitted the plants to a further careful examination under the micro- 
scope. Figs. 15, 16, 17, 18, 19, and 20, are drawings made from fungi 
grown in the box. 

We further varied the experiments in a variety of ways, and found that 
whenever the straw was exposed to a certain temperature, under the influ- 
ence of darkness and moisture, fungi were rapidly developed. We also 
found that' wheat or rye straw when stacked out or housed, unless unusu- 
ally dry, undergoes a greater or less degree of heating, fermentation or 



1862.] Salisbury, Effects of Fungi on Human System. 23 

decay, during which process a variety of fungi are developed, having the 
appearance of mould or mildew on the straw. When this straw is dis- 
turbed or agitated in any way the surrounding air becomes filled with innu- 
merable spores and cells of the broken and comminuted fungi. The indi- 
vidual cells and spores are too minute to be distinguished by the naked eye. 
They can only be seen when many are together and the air filled with them ; 
then they appear like a thin smoke or fine dust. Suspended in the air 
they are freely inhaled, tasting and smelling of old straw. This taste and 
smell is often quite persistent, lasting for hours. The air may be filled 
with them though invisible to us ; but generally their presence can be dis- 
covered by the taste and smell. These cells and spores are shown in Plate, 
Figs. 1, 2,' 3, 4, 9, 18, and 19. Those represented at Figs. 1, 18, and 19, 
make up by far the larger proportion. They are oval, and often several 
are attached to each other in a line, in the direction of their longest dia- 
meter. Figs. 2 and 9 represent spherical spores, much larger than those 
of Fig. 1, and united generally in masses instead of lines. Figs. 8 and 4 
represent large oval spores. Figs. 5 and 6 represent sporangia, which pro- 
duce the large oval spores 8 and 4. Fig. 6 appears to be a partially broken 
down sporangium. The plants are of a dull yellowish brown colour ; the 
sporangia of a light greenish yellow w^hite. Fig. a plant which pro- 
duces the spherical spores 2 and 9. It has four sporangia — two nearly 
mature and ready to shed their spores and two in process of development. 
The stems or mycelia of these plants are of a yellowish snuff colour; the 
sporangia are of a light greenish yellow white. Figs. 8 and 10 represent 
plants that produce spores like those of Fig. The colour of the mycelia 
and sporangia are also the same ; yet the arrangement of the sporangia 
on the mycelia seems to differ and may represent a different species. Figs. 
11 and 12 are plants with oval or egg-shaped sporangia, wdiich do not 
exceed one-thirtieth the size of those of 8 and 10. Their colour is an 
orange brown ; the mycelia are lighter. In this species, there is one main 
stem or mycelium with numerous branches, each bearing one or more spore 
cases. The branches are mostly made up of a single row of oval cells, like 
Fig. 1, attached end to end. Fig. 14 represents a plant from the sprout 
of a wheat kernel. The sporangia are small and nearly spherical. In this 
species there is a main stem with numerous short branches of nearly equal 
length, each terminated with a single spore case. The plants are of a light 
yellowish white colour. This species, or one similar to it, wdth generally 
shorter branches, is very common on the straw. Fig. 13 represents plants 
from the sprout of a wheat kernel. The whole plant appears to be dicho- 
tomous; colour, light greenish white. The sporangia are peculiar, being 
shaped like a tassel, with radiating lines of cells, attached to each other 
in the direction of their longest diameter, standing upon oval basidia. 
Fig. IT, plants from a straw that "was cut before it had matured. The 



24 



Salisbury, Effects of Fangi on Human System. [July 



plants are white with a yellowish tint. Each plant consists of a single 
branchless mycelium terminated by a small oval sporangium. 

Figs. 14, 15, and 16, are the plants which are by far the most common 
on the mature straw. They are very prolific ; maturing in from twelve to 
twenty-four hours under favourable circumstances ; having the appearance, 
to the naked eye, of short white mould or mildew, completely coating the 
stems. When the straw is agitated, the air is filled with thin minute 
elongated cells and spores. Figs. 1, 18, 19. These plants consist of a main 
stem — made up of interlacing cells — from which proceed numerous short 
branches (made up generally of a single line of cells), each one of which is 
either terminated by a small spherical sporangium or an enlarged cell. The 
plants Figs. 14, 15, and 16, are mingled together and are probably the same 
species. The branches of 14 and 15 are terminated with sporangia, while 
those of 16 are terminated simply by slightly enlarged cells. The plant 
Fig. 12, in frequency, ranks next to 14, 15, and 16, and is interspersed with 
them on the straw. When straw that is covered with these plants is 
slightly or carefully agitated, the cells and spores which are set at liberty 
and float in the air, are but little aggregated, as seen in Fig. 18. If the 
straw is agitated violently as in pitching it, the cells and spores set at 
liberty are more or less aggregated in masses and lines and mingled with 
them are the sporangia of plants Fig. 12 ; see Fig. 19. Fig. 20 is a peculiar 
white fungus, with a light straw tint, which occasionally is met with on the 
straw. It is, however, not common. The fungi, Figs. 5, 1, 8, and 10, we 
found generally on straw that had undergone further decomposition than 
that on which the others were met with. 

Inoculation of the Human System ivitJi the Spores and Cells of the 
Fungi of Wheat and Rye Straw. — Case I. At 10 o'clock P. M., Feb- 
ruary 11th, 1862, 1 inoculated my arm with the spores and cells of the fungi 
of wheat straw, which I obtained by placing a straw — covered with the 
plants — on a plate of glass, and hitting it with a few slight taps. On 
removing the straw, under and both sides of it was a white cloudy band, 
about ^ of an inch wide, running across the glass. These spores and cells 
lay so thick on the glass, that, to the naked eye, they seemed to touch each 
other. Their appearance under the microscope is represented in Fig. 1. 
The straw from which I obtained these cells came from a stack near this 
place, and was the same kind of straw as that used for beds at the camp. 
Under the microscope the fungi presented the same appearance, and the 
cells disengaged in agitating the straw were precisely similar. 

Wednesday, Feb. 12th, perfectly well. No inflammation or itching 
around the point of inoculation. 

13//?. Slight nausea. A very slight redness and itching at inoculating 
point. 

14//?. Got up with a feeling of lassitude and nausea, which continued all 
day. The redness and itching of inoculating wound increasing ; had diffi- 
culty in keeping warm ; chilly all day ; occasional sneezing ; eyes sensitive;' 
liad a peculiar feeling about the scalp, as if red pepper or mustard had been 
rubbed into the pores. 



1862.] Salisbury, Effects of Fungi on Human System. 25 



Saturday, Feb. 15. Nausea and lassitude continue ; occasional sneezing ; 
flashes of heat over the whole body ; itching and inflammation of the 
wound on the arm increasing ; thoughtlessly rubbed ofl' the scab, which was 
about three lines in diameter. The peculiar smarting, burning, congested 
sensation over the whole scalp, has increased since yesterday. It extends 
into the bone, with pains through the forehead and temples. A few blotches 
have made their appearance on the face and neck. Eyes weak and inflamed, 
so much so that I could not use them to read over half an hour during the 
evening. A heavy oppressive feeling about the chest ; mucous membrane 
of fauces and throat dry and irritated ; feel as if I had a severe cold. 

Sunday, Feb. 16. Had a sensation of weariness and drowsiness, with 
nausea, all day. Eyes red, inflamed, and sensitive ; smart, so that I can- 
not use them to read by gaslight. Whole scalp feels sore, with a constant, 
congested, burning sensation all through it to the bone. Arm itches ; red- 
ness as large as a dime. A heavy congested feeling about the chest ; have 
had more or less fever since Saturday morning. Throat and fauces dry and 
swollen, and voice hoarse. Pains in back and head have been almost con- 
stant since Friday last. 

Monday, Feb. 17th. The burning sensation of the scalp still continues. 
Eyes weak and inflamed ; cannot use them long at a time, without pain. 
There is still slight fever and nausea. 

Tuesday, Feb. 18th. Nausea ; face feels as if it had been exposed to the 
heat of an open fire till it had become inflamed. The peculiar burning 
soreness of the scalp is somewhat relieved. Eyes still sensitive ; catarrhal 
symptoms and fever less than yesterday. 

Wednesday, Feb. 19th. Yery much better; the soreness of scalp almost 
entirely relieved ; blotches and redness of face disappeared ; catarrhal symp- 
toms and fever gone ; eyes quite well. 

Case II. Wednesday Evening, Feb. 19th. Inoculated myself again in 
the same place, with the spores and cells of fungi as before. 

Thursday, Feb. 20th. Feel perfectly well, except a slight sensitiveness of 
the eyes. 

Friday, Feb. 2 1st. Same as yesterday. 

Sunday, March 2d. Have felt perfectly well since Feb. 21st. Eyes com- 
pletely recovered. 

Monday, March 3d. The last inoculation has produced no effect upon the 
system, that I can discover. 

Case III. Wednesday Evening, Feb. 19, 1862, inoculated my wife on 
her arm, with the spores and cells of the straw fungi. The cells were taken 
from the same group as those used in the second inoculation of my own 
arm, on the same evening. 

Thursday, Feb. 20th. Perfectly well all day. 

Friday, Feb. 21st. During the day, a dry constricting feeling of the 
throat made its appearance, and grew much worse during the following 
night. Voice hoarse ; has felt chilly through the day, with a feeling of 
lassitude and drowsiness. Nausea; ate no dinner. Throat and fauces in- 
flamed. 

Saturday, Feb. 22d. Nausea ; but little appetite ; severe pains through 
the forehead and temples ; tongue considerably furred ; throat feels dry 
and inflamed, with a very disagreeable constricting feeling, as if it would 
close up. A tumid appearance of fauces ; voice hoarse ; slight fever. 



26 



Salisbury, Effects of Fungi on Human System. 



[July 



Sunday, Feb. 23d. All through last night her throat felt as if it would 
close up. Rest very much disturbed. In the morning, throat felt better. 
Occasional sneezing ; voice hoarse ; some pain in swallowing. Stupid, 
weary, and inclined to sleep. 

Monday, Feb, 24th. Throat did not trouble her much last night; still 
hoarse ; head stopped up, as if with a cold ; towards evening a fulness and 
throbbing about the head, which felt sore. 

Tuesday, Feb. 25th. Had rather a restless night; head feels sore, swol- 
len, and heavy, as with a severe cold; eyes sensitive; catarrhal symptoms 
severe ; heaviness about the chest ; slight cough ; considerable lassitude and 
drowsiness; slept from 10 A.M. till 3 P. M. ; but little appetite. Had 
through the day occasional sensations of deafness ; slight redness in spots 
under the skin on the face. During the evening the pains in the head were 
relieved, and bowels became tender and sore. 

Wednesday, Feb. 26th. Had a good night's rest ; head relieved ; eyes 
still sensitive ; catarrhal symptoms subsiding ; chest feels easier ; bowels 
very sore and tender to the touch. Appetite returning ; redness on arm 
nearly gone ; slight itching yet. 

Thursday, Feb. 2Hh. Rapidly recovering ; head and eyes feel quite well ; 
bowels still slightly tender. 

Friday, July 28th, quite well. 

It will be seen from this case, that although there was scarcely any per- 
ceptible blotches, yet the other symptoms, such as chills, followed by fever, 
pains in the head, catarrhal symptoms, nausea, lassitude, &c., were all 
present. The disease commenced in the head, throat, and fauces, and 
passed downward, the bowels being very sore after the head, throat, and 
chest were relieved. 

Case IY. On Sunday, March 23d, 1862, Chas. B. Pierce, a fine healthy 
boy, six years of age, was exposed to measles, by contact with the disease. 

March 26th, seventy-two hours after the exposure, inoculated him with 
the fungi of wheat straw. The fungi were grown in my office, and shaken 
off from the straw on plates of glass, between which the spores and cells were 
preserved for use. On the second day after the inoculation (March 28th), 
a redness appeared around the inoculating point, about the size of a dime. 
This was preceded and accompanied by catarrhal symptoms resembling a 
slight cold. Did not complain. Played out of doors every day. This 
redness at the point of inoculation soon disappeared ; the catarrhal symp- 
toms subsided, leaving no bad effects ; and on April 2d, he was perfectly 
well. Forty -two days have passed since this boy was exposed to the dis- 
ease, and there are no signs of measles yet. 

Cases Y. to IX. Mr. Bartholomew, of Newark, Ohio, has a family of 
seven children, ranging from three to seventeen years of age. On Wednes- 
day morning, April 2d, Franklin Bartholomew, the next to the oldest son, 
broke out with measles. On Saturday evening, April 5th, three days after 
Franklin came down with the disease, and three days after the exposure of 
the entire family, I was called upon by Dr. Teller, their family physician, 
to go with him and inoculate the other six children and the mother, none 
of whom had ever had the disease. We inoculated the mother, and four 
of the children, leaving two boys — one thirteen and the other seventeen 



1862.] 



Salisbury, Effects of Fungi on Human System. 



21 



years of age — without being inoculated. On April 14th, the boy seventeen 
years of age, and on April 16th, the one thirteen years of age broke out 
with the disease. It has now been five weeks since the exposure of the 
mother and the four children inoculated. Although there has been three 
successive cases of measles in the house, none of those inoculated have had 
any symptoms of the disease. From twenty-four to thirty-six hours after 
the inobulation, !hey all had symptoms, resembling a slight cold, with a 
little chilliness, catarrhal symptoms and sneezing. Beyond this they have 
been perfectly well from the date of the inoculation to the time of this 
writing. May 5th. 

The inoculation does not produce a pustule and scab, like the vaccine 
virus, but simply a redness, around the wound, like a measle blotch. There 
is seldom any soreness, but usually a simple itching sensation for two or 
three days, extending generally from the second or third to the fifth or 
sixth day after the inoculation. 

Cases X. to XIII. April 12th, inoculated with rye straw fungus 

Mrs. , and two of her children, none of whom had ever had measles, 

and who had been exposed to the contagion of the disease from a case of 
genuine measles in the family, which broke out April 6th. On the evening 
of the 13th and morning of the 14th, they all had symptoms of chilliness 
followed by fever, catarrhal symptoms, slight cough and sneezing. The 
inoculating wound became red over a surface about the size of a dime, pre- 
senting the appearance of a measle blotch. 

Their symptoms were so slight that the children were not kept in doors, 
and the mother was not prevented from attending to her ordinary duties. 

On the 18th they had all quite recovered. It is now four weeks since 
the exposure, and no signs of measles in any of the cases inoculated. 

From the inoculations as far as they have gone, in from twenty -four to 
seventy-two hours, the effects begin to show themselves in lassitude, chilli- 
ness, catarrhal symptoms and pains through the forehead and temples. It 
is highly desirable that these experiments should be extended further. For 
this reason we publish thus early our observations and experiments (much 
more limited than we could have desired, on account of the difficulty in 
this place of obtaining subjects who are willing to sacrifice a few hours' 
health to such purposes) that others in larger places, who have greater 
facilities in the way of hospitals, &c., for carrying out more extended series 
of experiments under the eye of the attending physicians, may take up 
the matter and aid in its further investigation. 

I have not been able to distinguish thus far any difference between the 
eruption and attendant symptoms of genuine measles and "camp measles," 
or straw measles. When the disease is communicated to the human sub- 
ject, however, by inhaling the spores and cells of straw fungi, the eruption 
appears to follow the exposure or inhalation in from twenty-four to ninety- 
six hours. While in exposures to the contagion of the disease, the erup- 
tion does not usually make its appearance until from eleven to fourteen days 
thereafter. It is stated that in inoculations made by using matter obtained 



28 



Salisbury, Effects of Fungi on Human System. 



[July 



from the measle blotch, or by using the tears, blood, or salivary secretions 
of subjects broken out with the disease, the modified type of measles which 
results makes its appearance generally on the sixth or seventh day after 
the inoculation. In inoculating, however, with the spores and cells of 
straw fungi, the symptoms commence usually in about twenty-four hours; 
though sometimes they do not make their appearance till as late as seventy- 
two hours thereafter. 

This matter, however, requires further investigation before fully reliable 
statements can be made. 

To what extent inoculation with straw fungi may prove effectual in pro- 
tecting the human system against the contagion of measles can only be 
settled by careful and extended experiments. 

In Wood's Practice, under the head of Causes of Measles, we find the 
following statements, which we here quote, as they point indirectly to a 
possible origin of the disease somewhere in the direction of the results of 
these examinations. 

''Though capable of being propagated by contagion, measles prevail much 
more at some periods than at others ; probably under a peculiar epidemic influ- 
ence. Whether this influence is sufficient of itself to produce the disease ; or 
whether it merely acts by increasing the susceptibility to the contagious princi- 
ple, may perhaps be considered uncertain. If the fact quoted by Eayer from 
an old author, that the disease was not known in the new world until the year 
1518/ when it was imported from Europe, could be relied on, it would go far to 
prove that epidemic influence is alone insufiicient ; but the testimony can hardly 
be admitted to have much weight; and the very frequent occurrence of the dis- 
ease without any possibility of tracing the cause to personal communiccdion, 
ivould lead to the opposite conclusion} Still there is no impossibility in the 
production at once by the human body and by other unknown agencies in na- 
ture, of the same identical poison, whatever that may be. . The difficulty would 
be removed one step by admitting the vital organic character of contagions. 
Cold iveather^ appears favourable to the production of the disease, as epidemics 
of it are most frequent in winter. They occur, however, at all seasons. No 
age is exempt from the disease. It attacks the foetus in the womb and old per- 
sons in their second childhood. Yet it is much more freciuent in children than 
in adults. One reason of this may be a diminished susceptibility ; yet a much 
stronger one is the fact, that most persons have the disease in early life, and can 
have it but once. There is a general susceptibility to measles ; and there are 
very few who are not attacked at one or another period of their lives. 

" Though, as a general rule, measles are capable of being taken but once, in- 
stances have undoubtedly occurred, as in all other contagious diseases, in which 
the same individual has been affected a second- time." 



* Wheat and the other small grains were introduced into the new world about 
this time. Having no straw to generate the fungoid cause, they probably did not 
have the disease. 

2 It would, if there existed in the new world the proper material from which the 
cause or contagion emanates. If this be confined to the straw of our cereal grains 
and these were not known here previous to 1518, then there is a probability that 
the author, whom Rayer quotes from, may be correct. 

Wheat and the other small grains are generally threshed during the fall and . 
winter, and these are the seasons when the straw is the most used, and the periods 
when the disease usually occurs. When it occurs at other seasons, it is highly 
probable it may originate from straw beds. 



1862.] 



Flint, Cardiac Murmurs. 



29 



Art. II. — On Cardiac 3Turmiirs. By Austin Flint, M.D., Prof, of 
the Principles and Practice of Medicine in the Bellevue Hospital Medical 
College, N. Y., and in the Long Island College Hospital. 

The clinical study of cardiac murmurs, within the last few years, has led 
to our present knowledge of the diagnosis of valvular lesions of the heart. 
By means of the organic murmurs it is positively ascertained that lesions 
exist in cases in which, without taking cognizance of the murmurs, the 
existence of lesions could only be guessed at. The absence of the organic 
murmurs, on the other hand, enables us generally to conclude with positive- 
ness that valvular lesions do not exist. As a rule, to which there are but 
few exceptions, these lesions may be excluded, if there be no murmur. 
These are great results ; but the practical auscultator of the present day 
need not be told that the clinical study of cardiac murmurs has led still 
further into the mysteries of diagnosis. Having ascertained the different 
murmurs which occur in connection with valvular lesions ; having traced 
their connection, respectively, with different lesions ; having shown their 
relations to the movements of the several portions of the heart, and to the 
cardiac sounds-/ and, having explained satisfactorily the mechanism of 
their production, we are able to determine not only the existence or non- 
existence of valvular lesions, but their particular situation when they are 
present, and, to a certain extent, their character and consequences. The 
practiced auscultator, by listening to the murmurs alone, is able to tell 
whether lesions are situated at the mitral, or the aortic, or the pulmonic 
orifice, and he is able to say, in certain cases, that the valves which are to 
protect these orifices against a regurgitant current of blood, have been 
rendered by disease inadequate to their office. It is unnecessary to adduce 
proof of these statements ; their correctness is sufficiently known to those 
who are conversant with physical exploration as applied to the diagnosis 
of afi'ections of the heart. How strikingly do these facts exemplify the 
progress of practical medicine to those who, although still among the 
junior members of the jDrofession, have practised before and since the recent 
-developments in this department of our knowledge ! 

These remarks are introductory to the consideration of various practical 
points pertaining to the cardiac murmurs. And the first subject will relate 
to these murmurs in general — viz., the limitations of their significance. 
After having considered certain points embraced in this subject, I propose 
to take up various points relating to the different murmurs separately. 

' The conventional distinction between the cardiac sounds and murmurs is to be 
borne in mind ; t}ie former term being limited to the normal heart-sounds with 
their abnormal modifications, and the latter to newlj-developed or adventitious 
sounds, which are altogether the products of disease. 



30 



Flint, Cardiac Murmurs. 



By the limitations of the significance of the murmurs, I mean the actual 
amount of knowledge respecting valvular lesions to be derived from this 
source. It is evident, from what has been stated already, that the know- 
ledge which they convey is of very great importance, but, important as this 
knowledge is, it has certain limits which are not always sufficiently under- 
stood ; and, as a consequence, the practitioner is liable to fall into unfor- 
tunate errors of opinion as regards the gravity of the lesions which the 
murmurs represent. 

Prior to the clinical study of the cardiac murmurs, the existence of or- 
ganic affections of the heart was recognized when, in conjunction with 
disturbed action of the organ, symptomatic events had taken place which 
belong to an advanced stage of only a certain proportion of cases. Dys- 
pnoea, palpitation, and dropsy, were the symptoms mainly relied upon for 
the diagnosis. The recognized cases were then comparatively rare, and, 
when recognized, a speedily fatal issue was expected. This fact, together 
with the frequency with which cardiac lesions were revealed by post-mortem 
examinations in cases of sudden death, rendered the diagnosis of organic 
disease of the heart equivalent to a summons from the grave. The prog- 
nosis, as a matter of course, was as unfavourable as possible ; the doom of 
the patient was either to die unexpectedly at any moment, or to endure 
protracted sufferings until released by death. The study of the murmurs, 
together with the application of other signs, enabled the practitioner to 
recognize organic affections at a period in the disease when otherwise they 
would not have been discovered. The recognized cases became more fre- 
quent. Persons were found to have cardiac lesions who presented few or 
no symptoms pointing obviously to disease of the heart. The ideas which 
had prevailed relative to the gravity of organic affections, however, natu- 
rally enough, continued to prevail. An organic murmur, consequently, 
had a fearful significance. It was considered as proof of disease which was 
not less surely destructive because earlier ascertained. Let it be said of a 
patient that he had a cardiac murmur denoting a valvular lesion, and his 
doom was pronounced; sudden death, which might occur at any time, or 
an early development of the distressing symptoms characteristic of cardiac 
disease, were to be expected, whatever might be his present condition. 

So far from concealing from patients the fearful significance of cardiac 
murmurs, it was considered important for them to understand fully their 
precarious condition, in order to receive their co-operation in the measures 
of management which were deemed essential. These measures embraced 
general and local bloodletting, depletion by cathartics, sedative remedies 
addressed to the circulation, mercurialization, low diet, together with as 
much inaction of mind and body as possible. The consequences of this 
management were calamitous in the extreme. In fact, these measures' 
contributed, in no small degree, to the fulfilment of the gloomy predictions 
impressed upon the minds of the unfortunate patients who were found to 



1862.] 



Flint, Cardiac Murmurs. 



31 



present the auscultatory sign of valvular lesions. So long as these notions 
with regard to the treatment of cardiac affections prevailed, an early diag- 
nosis, instead of being desirable, was a serious disadvantage, and truly 
fortunate were they who kept aloof from the stethoscope of the auscultator ! 

Erroneous views respecting the significance of cardiac murmurs, and also 
respecting the indications for treatment in cases of organic disease of the 
heart, are still, to a greater or less extent, prevalent. I propose now to 
confine myself to the former, i. e., the significance of the murmurs. It is 
obvious that with the acquirement of means of ascertaining the existence 
of lesions at an early period, when, without these means, the lesions could 
not have been discovered, clinical experience had to take a new point of 
departure as regards prognosis. And experience has shown that lesions 
giving rise to cardiac murmurs by no means invariably denote impending 
danger or serious evils, and that they are not unfrequently innocuous. 
Several clinical observers, within the last few years, have contributed facts 
going to show the correctness of this statement. Of these. Dr. Stokes' is 
especially prominent. Dr. Gairdner, of Edinburgh, has lately communicated 
a valuable paper on this subject.^ I have been able to gather some facts 
having an important bearing on the subject under consideration. Of the 
cases which have come under my observation, exemplifying the ''limitations 
of the significance of cardiac murmurs," I shall select a few of the most 
striking. 

Thirteen years ago, I attended a child, aged 11 years, with a slight 
rheumatic attack. Directing attention to the heart, I found a very loud 
mitral, regurgitant murmur, heard over the left lateral surface of the chest 
and on the back. The heart was enlarged, the extent and degree of dulness 
in the pr^cordia being increased, and the apex beat without the nipple. 
The murmur was evidently not due to an endocarditis developed during the 
present attack of rheumatism ; the lesion giving rise to it probably origi- 
nated in an obscure thoracic affection which had occurred seven years before. 
I was at that time less acquainted with the significance of cardiac murmurs 
than now, and I deemed it my duty to inform the mother of the patient of 
the existence of an organic affection of the heart, which would be likely to 
destroy life within a period not very remote. The patient is still living. 
She is now 24 years of age, and, although presenting a delicate appearance, 
a casual observer would not suspect the existence of any disease. She is 
suliject to palpitation, to coldness of the extremities, and experiences want 
of breath on active exercise, but she does not consider herself an invalid, 
and the apprehensions caused by my communication . to the mother have 
long since disappeared. 

It is fair to presume that my opinion in this case was considered as a 
mistake. It was, indeed, an error of judgment as regards the prognosis, 
but the diagnosis was correct ; the loud bellows murmur is still there, and 

' Diseases of tlie Heart and Aorta. 

2 Edinburgh Monthly Journal of Med. Science. 



32 



Flint, Cardiac Murmurs. 



[Jnly 



heard over the whole chest, even through the dress, and the heart is con- 
siderably enlarged. The patient, if not destroyed by some intercurrent 
affection, will ultimately die of cardiac disease, yet it is now twenty years 
since the probable commencement of the lesions giving rise to the cardiac 
murmur. 

Nearly twenty years ago a person was examined by a medical friend with 
reference to an assurance on his life. My friend, finding a loud murmur, 
and an abnormally strong action of the heart, brought the person to me as 
an interesting case for examination. I failed to record the case, and am 
not therefore positive as regards the particular murmur present, but I think 
it was the mitral regurgitant. Since that examination, until recently, I 
have been in the habit of meeting this person often, although he has never 
been my patient. He has been, and still is engaged in active business. He 
is now about fifty years of age. He has survived his wife, and been again 
married within a few years. 

I have selected these two cases as illustrating the duration of' life and 
comfortable health for thirteen and twenty years after a loud organic mur- 
mur, together with enlargement of the heart, had been ascertained ; in both 
cases life and comfortable health continuing at the present moment, I 
could cite, in addition, numerous cases of persons now living, and appa- 
rently well, who have had organic murmurs for several years. In making 
examinations of chests, supposed to be healthy, for purposes of study, I 
have repeatedly found a murmur, evidently organic, when no disease of the 
heart was suspected either before or after my examination. The following 
case is instructive, as showing the Importance of taking into account the 
coexistence of functional disorder of the heart, dependent on anemia, with 
organic disease. 

In November, 1852, I visited, in consultation with Professor Kogers, of 
Louisville, a lady aged about 25. She had had repeated attacks of acute 
rheumatism. She had an infant several months old, which she was nursing, 
and she had become quite ansemic. She had begun to suffer from palpitation 
during the preceding summer, and her attention was attracted to a sound 
in the chest which she heard in the night-time. This sound was also heard 
by a sister with whom she slept. She described, of her own accord, the 
sound to be like that produced by a pair of bellows. She had never heard 
of cardiac bellows-murmurs, and at this time there had been no examination 
of the chest. Prof. Rogers had been called to the patient a short time 
before my visit, and detected at once the existence of organic disease. 

She presented an aortic direct and a mitral regurgitant murmur, both 
loud ; the heart was moderately enlarged, and its action violent. She was 
conscious of this violent action, and slight exercise or mental excitement 
occasioned much distress from palpitation. The urgent symptoms in the 
case were attributed to anaemia ; weaning was at once enjoined, and chaly- 
beate remedies, etc., advised. I met the patient a year afterwards without 
recognizing her. She was apparently in perfect health, and presented a 
blooming appearance. Her friends thought we must have been mistaken 
in our opinion as to the existence of organic disease of the heart. The 
murmurs and the signs of enlargement, however, were still there. She 



1862.] Flint, Cardiac Murmurs. 33 

continued to enjoy good health until the summer of 1856, when she suffered 
from uterine hemorrhage, and again became ansemic. The action of the 
heart became irregular, and she complained much of vertigo. Tonics, 
stimulants, nutritious diet and fresh air failed to remove the anaemic state, 
and at length she was seized with apoplexy and hemiplegia. She recovered 
from the apoplexy, but the hemiplegia continued, and death took place 
between two and three weeks after the apoplectic seizure. 

The significance of organic murmurs is limited to the points of informa- 
tion already stated in the introductory remarks, viz., the existence of lesions, 
their localization, and the fact of valvular insufficiency or regurgitation. 
Whether the lesions involve immediate danger to life, or, on the contrary, 
are compatible with many years of comfortable health, the murmurs do 
not inform us, nor do they teach us how far existing symptoms are referable 
to the lesions, and how far to functional disorder induced by other morbid 
conditions. Neither the intensity nor the quality of sound in the murmurs 
furnish any criteria by which the gravity of the lesions or their innocuous- 
ness can be determined. A loud murmur is even more likely to be pro- 
duced in connection with comparatively unimportant lesions than with 
those of a grave character, because in the former, rather than in the latter 
case, is the action of the heart likely to be strong, and the intensity of the 
murmur, other things being equal, will depend on the force with which the 
currents of blood are moved. Whether the murmur be soft, or rough, or 
musical, depends not on the amount of damage which the lesions have 
occasioned, but on physical circumstances alike consistent with trivial and 
grave affections. 

It may be imagined that these assertions, although true as regards 
murmurs produced by the direct currents of blood, do not hold good with 
respect to the regurgitant murmurs. The latter, it may be said, involving 
as they do insufficiency of the valves, will be loud in proportion to the 
amount of blood which regurgitates, and, therefore, the intensity of the 
murmur should be a criterion of the amount of valvular insufficiency. 
But clinical observation disproves this surmise. A minute regurgitant 
stream is as likely to be intensely murmuring as a large current, perhaps 
even more so. Here, too,, the loudness of the sound will depend, in a great 
m.easure, on the power of the heart's action. To this point I shall recur 
when I come to consider the different murmurs separately. 

The practical injunction to be enforced in connection with the limitatioas 
of the significance of the cardiac murmurs is^ that we are not to j;Udge of 
the magnitude of valvular lesions, of the amount of danger on the one 
hand, or of the absence of danger on the other liand, by the characters 
Monging to the murmurs. The physician who undertakes to interrogate 
the heart by auscultation is not to decide that the condition of his patient 
is alarming, simply because he finds a murmur which he satisfies himself is 
dependent on an organic lesion of some kind. The lesion may be at that 
Ko. LXXXYII.— July 1862, S 



34 Flint, Cardiac Murmurs. [July 

time, and perhaps ever afterwards, innocuous ; the evils arising from cardiac 
affections maybe remote, and so far from plunging the patient into despair 
by the announcement of the fact that he has an incurable disease of heart, 
there may be just grounds for holding out expectations of life and com- 
fortable-health for an indefinite period. Neither does it necessarily alter 
the case when more than one murmur is discovered ; the existence of several 
murmurs by no means excludes the possibility of similar encouragement. 
We are to look to other sources of information than the murmurs in forming 
an opinion respecting the gravity of the affection. What are the sources 
of information on which our opinion is to be based ? It does not fall 
within the scope of this essay to consider at length the points involved in 
the answer to this inquiry. I shall answer it in a few words. 

The heart-sounds furnish means of determining whether the lesions are 
of a nature to affect materially the function of the valves. I must here 
pass by this useful and beautiful application of auscultation with a simple 
allusion to it, referring the reader • elsewhere for a full exposition of the 
subject.* I shall, however, return to the subject presently in considering 
the murmurs individually. Means requiring less proficiency in physical 
exploration relate to enlargement of the heart. It is not a difficult problem 
to determine whether the heart be or be not enlarged, and it is easy to 
determine the degree of enlargement. Now, in general, if valvular lesions 
have not led to enlargement of the heart, they are not immediately 
dangerous, and the danger is more or less remote. Here is a criterion of 
great importance in estimating the gravity, on the one hand, or the present 
innocuousness on the other hand, of lesions giving rise to murmurs. So 
long as the heart be not enlarged, the lesions cannot have occasioned to 
much extent those disturbances which arise from contraction or patency 
of the orifices. The murmurs, in themselves, give no information respect- 
ing the amount of obstruction from contracted orifices, or of regurgitation 
from valvular insufficiency. Let this fact be constantly borne in mind. 
But obstruction and regurgitation singly or combined, inevitably lead to 
enlargement of the heart ; hence the latter becomes evidence of the former. 
The degree of enlargement is, in general, a guide to the extent and duration 
of the disturbances occasioned by contracted and patescent orifices. As a 
rule, if the heart be slightly or moderately enlarged, the immediate danger 
from the lesions which may give rise to one or more loud murmurs is not 
great. 

The truth is, the evils and danger arising from valvular lesions, for the 
most part, are not dependent directly on these lesions, but on the enlarge- 
ment of the heart resulting from the lesions. We may go a step further 
than this and say that, ordinarily, serious consequences of valvular lesions 

' Clinical Study of the Heart-sounds in Health and Disease, Prize Essay, Trans. 
.Amer. Med. Association, 185y. 



1862.] Flint, Cardiac Murmurs. 35 

do not follow until the heart becomes weakened either by dilatation or by 
degenerative changes of tissue. So long as the enlargement be due mainly 
to hypertrophy of the muscular walls, the patient is comparatively safe. 
Hypertrophy is a compensatory provision, the augmented power of the 
heart's action enabling the organ to carry on the circulation in spite of the 
disturbance due to obstruction and regurgitation. Happily, in most cases, 
hypertrophy is the first effect of valvular lesions, and, for a time, it keeps 
pace with the progress of the latter. Dilatation, which weakens the 
heart's action, is an effect consecutive to hypertrophy, and, as a rule, it is 
not until the dilatation predominates that distressing and dangerous evils 
are manifested.. 

The practical bearing of these views respecting hypertrophy and dilata- 
tion, on the management of organic affections of the heart, is obvious. 
They are inconsistent with the employment of measures to prevent or 
diminish hypertrophy ; on the contrary, they point to the importance of 
an opposite end of management, viz., to encourage hypertrophy in prefer- 
ence to dilatation, and to maintain the vigour of the heart's action. It 
does not fall within the scope of this essay to consider therapeutical appli- 
cations, and I must content myself with this passing notice of an immensely 
important reform in the management of organic affections of the heart. 

Returning to the means of determining the gravity of valvular lesions, 
I repeat, they become serious, in other words, the distressing and dangerous 
symptomatic events are to be expected, in proportion as hypertrophy 
merges into dilatation, or as weakness of the organ may be induced by 
structural degeneration or other causes. In connection, then, with murmurs, 
we are to determine the condition of the heart as respects the points just 
mentioned, in order to estimate properly the gravity of the lesions which 
the murmurs represent. In leaving this subject, viz., the limited signifi- 
cance of the cardiac murmurs, I will give a case which is a type of a class 
of cases not unfrequently coming under observation. 

In the spring of 1860, I was consulted by a medical gentleman from a 
distant State, who furnished me with the following written statement of 
his case : — 

" About a year ago I went to the city of to place myself under the care 

of Dr. , for a trifling surgical difficulty with which I had been annoyed for 

a long time. At long intervals previous to that time I had had severe pains in 
the left breast about the cardiac region, but at no time from any coustant pain. 

I thought the pain was of a neuralgic character. While at • I thought I 

would have my lungs examined, as some members of my family had been con- 
sumptive. I went to Dr. and to Dr. , both of whom pronounced my 

lungs sound, but said that my heart was affected. I came home much depressed 
by their opinion, and suffered so much from mental anxiety that in the course of 
a month or two I determined to go back and consult another medical gentleman. 

Dr. . He told me there was some roughness about the sounds of the heart 

but no serious organic disease. I was much relieved by this opinion, and clung 
to the belief that the pains were of a neuralgic character.' Previous to my 

' Doubtless thej were so. 



36 



Flint, Cardiac Murmurs. 



[July 



going to I had all my life taken a good deal of out-door exercise, such as 

riding, hunting, fishing, etc., for the purpose of warding off any tendency to 
consumption. I have always had a frail figure and been inclined to despondency. 
I have suffered a great deal of anxiety, owing to family afiairs and business 

matters. After my return from consulting Dr. I thought it best to give up 

active exercise for fear of increasing any cardiac affection that might exist. I 
do not think that I have had any severe pain in my chest frequently, at 
any time, but only at intervals and apparently occasioned by anxiety about 
patients, etc. 

"In December last I went into the country, 13 miles, to see a patient. The 
weather was very cold, rainy, and windy ; I returned in the night. I was suffer- 
ing from toothache and smoked a cigar in order to relieve the pain. I went 
over to my office to write a prescription for a sick child, and on my way back I 
was attacked with palpitation of the heart for the first time in my life. I came 
into the house and lay down, when I was seized with severe rigors without 
chills. I had also pain in the back and afterwards fever. Since then I have 
been subject, at intervals, to a jarring or knocking sensation about the heart, 
but no palpitation of long continuance. I cannot sleep as well on my left side 
as formerly, as it causes an uneasy sensation with something like palpitation 
and some pain. I do not take much exercise, and find that I get out of breath 
easily. I am very sensitive to cold. The attacks of increased action of the 
heart are always accompanied by rigors and irritability of the bladder. On the 
19th of March, I was taken with a feeling of fatigue and indigestion, followed 
by severe rigors together with great heat of the head and body. The circula-' 
tion was rapid and accompanied by palpitation. The attack lasted nearly an 
hour, and I feel the effect of it to-day, March 22d. I notice, when reading a 
newspaper or small book, that the action of the heart causes it to vibrate. 
During my first attack in Dec, I had an intermittent pulse. I did not recover 
from that attack so as to go out for a week, and have not since been as well as 
before. 

"Fearing that my situation was critical I have been careful of myself. I 
have feared to increase the affection and that I might die suddenly. But I have 
had fear that in taking care of the cardiac affection I shall increase a tendency 
to consumption. Any mental anxiety increases the action of the heart. I do 
not smoke nor chew tobacco, nor drink any alcoholic liquors. I have suffered 
much from toothache ; in other respects have had generally very good health. 
I have never had rheumatism. I am a married man with five children. I think 
my cardiac affection has been getting worse since December last, and I suffer in 
mind dreadfully on that account, as I have a great deal to live for." 

On examination of the chest, in this case, I found the apex-beat in the 
5th intercostal space half an inch within a vertical line passing through 
the nipple. The area of superficial cardiac dulness carefully delineated on 
the chest, was found to be of normal extent. The left border of the heart 
fell within the nipple. The respiratory murmur, on a deep inspiration, 
was heard over the whole pr^ecordia. The apex-beat was not abnormally 
strong ; no other impulse was discovered, and no heaving of the prtecordia. 

At the first examination, the heart being but little excited, I discovered a 
slight murmur just to the left of the apex, heard only during the latter 
part of each inspiratory act. T could discover no murmur at the base. At 
a subsequent examination on the same day, made after dinner, the patient 
having drank a little wine with his dinner, the action of the heart was 
much greater than at the previous examination. I then discovered a well- 
marked systolic murmur at the apex, to the left of the apex and at the 
lower angle of the scapula ; I also ascertained the existence of a soft sys- 
tolic murmur at the base on the left side of the sternum and not on the 
right side. This murmur extended over the whole summit of the chest on 
the left side. At the summit it came evidently from the subclavian, as the 



1862.-] 



Flint, Cardiac Murmurs. 



87 



pitch differed from that of the murmur over the pulmonary artery, i. e., in 
the 2d intercostal space on the left side. 

On the next morning I made an examination while the patient was still 
in bed. The heart was then acting tranquilly. I discovered a feeble 
murmur at the apex only ; this murmur was not perceived behind, and no 
murmur was heard at the base. 

The aortic and pulmonic second sounds were normal, and so also were 
the mitral and tricuspid valvular elements of the first sound. 

I shall quote from my record book the remarks which were appended to 
this case when the record was made : — 

"The heart is but little if at all enlarged, and the heart sounds are normal. 
There exist, therefore, no lesions which at present are of serious import. 
Tlie cardiac trouble which has occasioned the patient so much unhappiness 
and anxiety, is purely functional. 

"Dr. (who first examined this patient) evidently discovered a 

murmur. His examination was not very critical, and was made after the 
patient had just mounted stairs at his hotel. The opinion that there was 
organic disease without any qualifying explanations produced a profound 

moral impression on the patient. The opinion of Dr. ■ subsequently 

did something toward relieving the apprehensions of the patient ; but his 
coming such a long distance to consult me is evidence how much his mind 
was ill at ease on the subject." 

" The heart is not entirely free from lesions ; there is slight mitral regur- 
gitation. The murmur at the base is perhaps inorganic, or at all events 
it does not denote important valvular lesions, since a comparison of the 
aortic and pulmonic sounds shows the two to be in a normal relation to 
each other. The lesions in fact which exist in the case are of no immediate 
seriousness, and of this I assured the patient in the most positive manner." 

"This case affords an illustration of the importance of discriminating 
between functional disorder and the effects of organic disease when there is 
evidence of the latter. It illustrates, also, the importance of the heart 
sounds and of the size of the heart in determining the gravity of lesions. 
The evils which may arise from the lesions (if they ever occur) are remote, 
and I felt warranted in assuring the patient that his condition involved no 
present danger, and that he might dismiss all thoughts of disease of the 
heart. I ordered him to live well and to resume his out-door sports. His 
apprehensions were entirely relieved by my assurances, and his expressions 
of gratification afforded evidence of what he had suffered mentally from the 
idea of an organic disease incapacitating him for the duties of life and 
randering him liable to sudden death." 

As I have said, this case is a type of a class of cases of not unfrequent 
occurrence. The existence of a cardiac murmur was discovered in conse- 
quence of an examination with reference to the lungs. Prior to this time 
no symptoms of disorder of the heart existed ; the discovery of the murmur 
was an unfortunate circumstance for the patient ; the belief that he had 
serious disease of heart became fixed in his mind, and doubtless contributed 
to the disorder which subsequently occurred. The functional disorder was 
slight in comparison with cases which are of daily occurrence ; but the 
patient naturally attributed it to organic disease. The affection was in 



38 



Flint, Cardiac Murmurs. 



fact altogether functional, albeit the existence of an organic murmur ; this 
is the practical point which the case is intended to illustrate. 

I propose now to consider certain practical points pertaining to the 
cardiac murmur separately ; I shall limit my remarks mainly to the mur- 
murs produced by the blood-currents, in the left side of the heart, viz., the 
aortic direct, the aortic regurgitant, the mitral systolic and the mitral 
direct. Exclusive of the pulmonic direct murmur I have but little prac- 
tical acquaintance with murmurs emanating from the right side of the 
heart. 

Aortic direct murmur. — The question whether a murmur be organic or 
inorganic has reference generally to a murmur produced by the current of 
blood from the left ventricle into the aorta. The aortic regurgitant mur- 
mur and a mitral murmur which is truly regurgitant are of necessity 
organic; they require lesions involving more or less insufficiency of the 
valves. The mitral direct murmur, as will be seen presently, is inorganic 
only as a rare exception to the rule. A practical point, then, in certain 
cases, is to determine whether an existing aortic direct murmur be organic, 
i. e., dependent on lesions, or whether it be inorganic, i. e., dependent on a 
blood-change. This point cannot always be positively settled, but when 
such is the case it is practically not very important that it should be settled ; 
in other words, when a murmur exists concerning which we are at a loss 
to decide whether it be organic or inorganic, if it be the former, the lesion 
giving rise to it must be trivial, since under these circumstances the heart 
sounds will be found to be normal and the heart not enlarged. If in con- 
nection with an aortic direct murmur we find the aortic second sound 
impaired and the heart enlarged, we are warranted in considering the 
murmur organic. But a slight rippling of the current by roughening 
from an atheromatous or calcareous deposit which occasions no obstruction, 
and no valvular insufficiency, may yield a murmur. How are we to dis- 
tinguish this from an inorganic murmur ? The absence of the anaemic 
state, of other cardiac murmurs, of arterial murmurs, of the venous hum, 
and the persistency and uniformity of the murmur are the circumstances 
which render it probable that it is organic ; while the existence of anaemia, 
of other cardiac murmurs, of arterial murmurs and the venous hum, together 
with intermittency and variableness of the murmur, render it probable that 
it is inorganic. 

In my work on diseases of the heart, 1859, I have stated roughness of 
the murmur to be one of the circumstances showing it to be organic. I 
then believed that an inorganic murmur was never rough. The able reviewer 
of my work in the Dublin Quarterly says, with regard to this point, "We 
are unable to give unqualified assent to the statement that an inorganic 
murmur is uniformly soft." The criticism of the reviewer is just; I was 
mistaken in the statement as the following case will show: — 



1862.] 



Flint, Cardiac Murmurs. 



39 



I visited in May, 1860, a female patient who presented a loud rasping 
murmur which had led to the suspicion of aneurism. The patient was 
exceedingly anaemic ; there was total loss of appetite with vomiting and 
diarrhoea. The anemia could not be accounted for; it belonged in the 
category of cases described by Addison as cases of idiopathic ansemia. I 
found a rough rasping murmur at the base of the heart on the right of the 
sternum, and a similar murmur was heard over the subclavian and carotid. 
On examination after death, in this case, the heart was perfectly normal, 
the aortic orifice, the aorta, subclavians, and carotids were free from any 
morbid change, and the lungs were healthy. The murmur was evidently 
due to a blood change. 

The discrimination of an aortic direct from a pulmonic direct murmur 
is a point of interest. If the normal situation of the aortic and pulmonic 
artery in relation to the walls of the chest be preserved, an aortic direct 
murmur has its maximum of intensity and may be limited to the point 
where the aorta is nearest the surface, viz., the second intercostal space on 
the right side close to the sternum. But the normal relation of the vessels 
to the thoracic walls is not infrequently changed when the heart becomes 
enlarged, or as a consequence of past or present pulmonary disease, and 
hence this murmur may be loudest or limited to the base on the left side 
of the sternum. The situation of the murmur or of its maximum, there- 
fore, is not always reliable in the discrimination. A pulmonic direct 
murmur has its maximum or is limited to the second or third intercostal 
spaces on the left side close to the sternum, the artery being at these points 
nearest the surface, but, as just stated, an aortic direct murmur may be 
found to be loudest in this situation. If the heart be not enlarged or 
displaced by pressure from below the diaphragm, the chest not depressed, 
and the lungs are free from disease, the fact that a murmur has its maxi- 
mum at or is limited to the right side of the sternum, is evidence of its 
being aortic rather than pulmonic, and per contra, the fact of a murmur 
having its maximum at or being limited to the left side of the sternum, is 
evidence of its being pulmonic rather than aortic. But the propagation 
of the murmur into the carotid is the most important circumstance in this 
discrimination. An aortic direct murmur, unless it be quite weak, is 
generally propagated into the carotid. A pulmonic direct murmur of 
course cannot be. Here attention to the pitch and quality of sound is 
called into requisition. It is to be determined that a murmur heard 
over the carotid is propagated from the aorta not produced within the 
carotid. How is this to be determined ? Yery easily in most cases, by a 
simple comparison of the murmur as heard over the carotid and at the 
aortic orifice. If the murmur in the neck be a propagated murmur it will 
differ from that at the base of the heart chiefly as regards intensity ; the 
pitch and quality will not be materially changed. If it be rough or soft at 
the base of the heart, it will be the same in the neck ; if the pitch be high 
or low at the base of the heart, it will be the same in the neck. On the 



40 



Flint, Cardiac Murraurs. 



[July 



other hand, a murmur produced within the carotid, will be likely, in the 
great majority of cases to differ in quality and pitch from a coexisting 
murmur at the aortic orifice. 

In accordance with what has been stated with reference to the limitations 
of the significance of organic murmurs in general, an aortic direct murmur, 
when undoubtedly organic, alone affords little or no information respecting 
the nature and extent of the lesions which give rise to it. A comparison 
of the aortic with the pulmonic second sound of the heart enables us fre- 
quently to form an opinion as regards the amount of damage which the 
aortic valve may have sustained. The aortic second sound, in health, as 
heard in the right second intercostal space near the sternum, is more intense, 
and has a more marked valvular quality, than the pulmonic second sound 
as heard in a corresponding situation on the left side. Now, it is often 
easy to determine whether the intensity of the aortic second sound is 
diminished and its valvular quality impaired ; and in proportion as this 
sound is abnormally altered in these respects, we may infer that the aortic 
valve is damaged. It is hardly necessary to say that, in order for this 
comparison to warrant the inference just stated, pulmonary disease must 
be excluded. A tuberculous deposit, for example, on the left side, may, by 
conduction, render the pulmonic apparently more intense than the aortic 
sound, the latter retaining its normal intensity ; the same will occur from 
shrinking of the upper lobe of the left lung so as to bring the pulmonic 
artery into contact with the thoracic walls. Under the latter circumstances 
the pulsation of the pulmonic artery may sometimes be distinctly felt in 
the second left intercostal space near the sternum. I have met with two 
cases during the past winter in which the pulsation of the pulmonic 
artery was so strong as to suggest the idea of aneurism; in both cases the 
patients were affected with tuberculous disease of the left lung. Alteration 
of the normal relation of the aorta and pulmonic artery due to enlargement 
of the heart, or to any of the causes already mentioned, will of course 
preclude a comparison of the two sounds. 

With reference to the value of a comparison of the aortic and pulmonic 
second sound in estimating the amount of aortic lesions, the able reviewer 
in the Dublin Quarterly, to whom I have already referred, and for whose 
valuable criticisms I beg to avail myself of this opportunity of expressing 
my sincere thanks, remarks as follows:- — 

" It is observed, to our great wonder, that if the aortic second sound retain 
its normal intensity and purity, it shows that the aortic valve is competent to 
fulfil its function, a fact which warrants the exclusion of lesions affecting it 
sn.fficienth/ to give rise to ohstruction." He adds, " Surely Dr. Flint must have 
become clinically cognizant of the fact that there is not unfrequently serious 
contraction of the aortic orifice producing marked obstruction and hypertrophy 
of the left ventricle, the aortic second sound remaining intact." 

Tills criticism is not altogether just. I state that the normal intensity and 
purity of the aortic second sound warrant the exclusion of lesions affecting 



1862.] 



Flint, Cardiac Murmurs. 



41 



it, i. e., the vake, sufficiently to give rise to obstruction. I do not say 
that contraction of the aortic orifice may not occur without involving the 
aortic valve, and, in such a case, the aortic second sound may remain intact. 
In fact, I imply this when I proceed to say, "In a large proportion of the 
cases of obstructive lesions of the aortic orifice, the valve is involved 
sufficiently to compromise, to a greater or less extent, its function and 
impair the intensity of the aortic second sound." This language is equiva- 
lent to admitting that there is a small proportion of cases of obstructive 
lesions of the aortic orifice, in which the valve is not involved sufficiently 
to compromise its function and impair the intensity of the aortic second 
sound. These exceptional cases are extremely rare. Surely the able 
reviewer will admit that, in the great majority of cases, the valve is involved 
so as to impair its function to a greater or less extent. 

I have lately been interested in a nice point of observation connected 
with the murmur under consideration, viz., the concurrence of two aortic 
direct murmurs, one produced at the aortic orifice and another within the 
aorta just above the orifice. One of the murmurs may be organic and the 
other inorganic, or both murmurs may be organic. At the present moment 
I have under observation three cases of endocarditis with rheumatism, each 
presenting a high pitched basic murmur when the stethoscope is placed over 
the sternum and a little to the right of the median line, the murmur limited 
to a circumscribed space, and just above this point, in the right second 
intercostal space, is another murmur difi'ering from the former notably in 
pitch, being quite low. In one of these cases there is still another murmur 
in the pulmonic artery. The high pitched murmur just below the second 
intercostal space, as I infer from the situation to which it is limited, is a 
murmur produced at the aortic orifice ; and the low pitched murmur just 
above, as I infer, also, from the situation to which it is limited, is an aortic 
murmur produced within the artery above the aortic orifice. I infer that 
there are two murmurs from the notable difference in pitch, it being by no 
means probable that a single sound would be so much altered within the 
area in which the two murmurs are heard, this area not being larger than 
a half dollar. That an aortic murmur is sometimes produced at the orifice 
and sometimes within the artery above the orifice, in different cases, is cer- 
tain, but I am not aware that the production of a murmur in each situation, 
at the same time, in the same case, and the discrimination of the two by 
means of the character of the sound, have been pointed out. 

Aortic regurgitant murmur. — This murmur need never, as a matter of 
course, be confounded with the systolic murmurs, viz., the aortic direct, and 
mitral regurgitant, the latter occurring with the first, and the former with 
the second sound of the heart. In general, too, there is no difficulty in 
distinguishing the aortic regurgitant, from the mitral direct murmur. The 
former occurs with and follows the second sound, the latter precedes the 



42 



Flint, Cardiac Murmurs. 



[July 



first sound.. The one is diastolic, . the other is pre-systolic. This is a 
distinction, nice, it is true, but easily appreciable in practice, to which I 
shall recur under the heading of the mitral direct murmur. 

The situation of the murmur is also distinctive. It is best heard at, 
and below the base of the heart. Usually it is best heard below the base 
to the left of the median line on a level with the third or fourth ribs. This 
is doubted by the reviewer in the Dublin Quarterly, to whom I have 
referred, but as the statement is based on a pretty large number of recorded 
observations, I must consider it as correct. It is not uncommon to hear 
this murmur distinctly, and even loudly, over the apex ; it may be diffused 
over the whole prsecordia and even propagated beyond this region. 

An aortic murmur with the second sound of the heart, propagated below 
the base of the heart, necessarily implies regurgitation, in other words 
there must be insufficiency of the aortic valvular segments. But it is 
always to be borne in mind that no inference can be drawn from the inten- 
sity or character of the murmur, respecting the amount of insufficiency 
and consequent regurgitation. An extremely small regurgitant stream 
may give rise to a loud murmur, while a feeble murmur may accompany a 
large regurgitant current, as the rippling brook is noisy while the deep 
broad river flows silently. In a case recently under observation, there 
existed a loud aortic regurgitant murmur, and on examination after death 
the aortic segments were so slightly impaired that, on cursory inspection, 
they might have been considered as normal. Weakening or extinction of 
the aortic second sound of the heart are points of importance as showing 
frequently the extent to which the function of the aortic valve is impaired. 
Comparison with the pulmonic sound enables us to judge whether the aortic 
sound be impaired, provided the pulmonic sound be not abnormally intensi- 
fied as a result of coexisting mitral lesions. It is important to recollect 
that when aortic and mitral lesions coexist, the intensity of the pulmonic 
sound cannot be taken as a criterion for judging whether the aortic sound 
be, or be not weakened. This remark is equally applicable to the com- 
parison in cases in which an aortic direct murmur is present. It is needless 
to say that in comparing the aortic and pulmonic sound in connection with 
an aortic regurgitant, as with an aortic direct murmur, pulmonary disease 
is to be excluded, i. e., solidification or shrinking of the left lung will, as 
already stated, render the pulmonic sound relatively more intense than the 
aortic, irrespective of, on the one hand, any actual increase of the intensity 
of that sound, or, on the other hand, of any weakening of the aortic sound. 
It is also to be stated here, as heretofore, that an alteration of the situation 
of the aorta and pulmonary artery as regards the thoracic walls, due to 
enlargement of the heart, or other causes, will preclude a comparison of 
the two sounds with reference either to intensification of the pulmonic, or 
weakening of the aortic sound. 



1862.] 



Flint, Cardiac Murmurs. 



43 



Mitral systolic murmur. — I use the phrase mitral systolic, instead of 
that more commonly used, viz., mitral regurgitant murmur, as applied to any 
murmur produced at the mitral orifice and accompanying the first sound of 
the heart. If the latter term be applied to any systolic murmur emanating 
from the mitral orifice, we fall into the solecism of calling a murmur regur- 
gitant in cases in which there is no regurgitation. A mitral murmur may 
be produced by mere roughness of the valvular curtains when there is no 
insufiiciency of the valve. In this case the murmur cannot be correctly 
said to be regurgitant. A mitral systolic murmur, thus, may or may not 
be a regurgitant murmur, and, to express this important distinction, we 
may say that a mitral systolic murmur exists with or without regurgitation. 
The question at once arises, how are we to determine whether a mitral 
systolic murmur be regurgitant or non-regurgitant ? This point claims 
consideration. 

A mitral systolic murmur, as is well known, generally has its maximum 
of intensity at, and the murmuring may be limited to, the situation of the 
apex-beat, or to the point where the intensity of the first sound of the 
heart is greatest. The murmur may be diffused, in the first place, within 
this point over the body of the heart, and, in tlie second place, without the 
apex over the left lateral surface of the chest and on the back. I have 
been led to believe that when the murmur is diffused over the left lateral 
surface and more or less over the back, it always denotes regurgitation, and 
that when the murmur is not propagated much without the apex, although 
it may be more or less diffused over the body of the heart, it may be produced 
within the ventricle and not by a regurgitant current. In the latter case 
I have distinguished the murmur as an intra-ventricular murmur, and not 
considered it as affording any evidence of insuflQciency of the mitral valve. 
It is this intra-ventricular, or mitral systolic non-regurgitant murmur, 
which generally exists in rheumatic endocarditis. The importance of the 
point involved is obvious, for a murmur emanating from the mitral orifice 
without valvular insufficiency or regurgitation, denotes lesions of little 
immediate consequence, and they may be innocuous, not only for the present 
but for the future. 

The practical rule just stated, I believe, generally holds good ; but there 
may be exceptions. The following is perhaps an exceptional instance : a 
case was recently under my observation in Bellevue Hospital, in which acute 
rheumatism was complicated with endocarditis, pericarditis, and pleurisy, 
with considerable effusion, affecting the left side. This patient presented, 
on admission, a loud pericardial friction sound diffused over the whole 
prsecordia, and a loud mitral systolic murmur. The latter had its maxi- 
mum of intensity at the apex, but was diffused over the left lateral surface 
of the chest and heard on the back. After the lapse of about a week the 
friction sound disappeared ; but before the disappearance of the friction 
sound, the endocardial murmur had gradually diminished and disappeared. 



44 



Flint, Cardiac Murmurs. 



[July 



The pleuritic efifusion also disappeared, and evidence was afforded in this 
case of pericardial adhesions by the immobility of the apex-beat when the 
body of the patient was placed in different positions. The disappearance 
of an endocardial murmur developed by rheumatic endocarditis, so far as 
my observation goes, is rare, although I have met with other examples. 
I suppose that endocarditis does not involve actual regurgitation save as a 
remote consequence of lesions to which the endocarditis may give rise. 1 
may be mistaken in this supposition, but, assuming that I am not, here 
was an instance in which an intra-ventricular or non-regurgitant mitral 
systolic murmur was propagated entirely around the chest. 

With reference to determining the existence of either regurgitation or 
obstruction, or both, resulting from mitral lesions, a comparison of the 
aortic and pulmonic second sound, forms a beautiful and useful application 
of auscultation. Obstructive and regurgitant lesions, situated at the mitral 
orifice, involving an obstacle to the free passage of blood through the pul- 
monary circuit, give rise, as is well known, to hypertrophy of the right 
ventricle. In this way they lead to intensification of the pulmonic second 
sound of the heart. This effect is due, in part, to the augmented power of 
the contractions of the right ventricle, and, in part, to the resistance to 
the passage of blood through the lungs, both continuing to increase the 
dilatation of the pulmonary artery by the pulmonic direct current, and the 
consequent recoil of the arterial coats by which the pulmonic valvular 
segments are expanded, and the pulmonic second sound produced. But 
the morbid disparity between the aortic and pulmonic second sound is due, 
not alone to the intensification of the latter in the manner just stated. 
The aortic second sound is weakened in proportion to the amount of blood 
which fails to pass into the aorta with the ventricular systole, in conse- 
quence of the mitral obstruction or regurgitation. It is obvious that the 
aortic direct current will be lessened by the amount of blood which, in con- 
sequence of valvular insufficiency, flows backward into the left auricle after 
the ventricle contracts, and by the amount of difficulty which exists in the 
free passage of blood from the auricle into the ventricle in consequence of 
a contracted orifice. It is also obvious that, other things being equal, the 
intensity of the aortic second sound will be greater or less according to the 
quantity of blood propelled into the aorta by the ventricular systole. Thus 
it is clear how mitral obstruction and regurgitation lead to weakening of 
the aortic sound, as well as to intensification of the pulmonic sound, and 
both effects are abundantly attested by clinical observation. 

The degree of weakening of the aortic and of intensification of the pul- 
monic sound will be proportionate to the amount of mitral regurgitation 
or obstruction, or both. We have then, in this application of ausculta- 
tion, a means of obtaining information respecting the extent or gravity of 
mitral lesions. And, in a negative point of view, this application is im- 
portant, viz., as a means of determining that lesions which give rise to a 



1862.] 



Flint, Cavdiac Murmurs. 



45 



murmur are not serious ; in other words, of determining that they do not 
involve much, if any, obstruction or regurgitation. As enabling us to 
exclude obstructive or regurgitant lesions in certain of the cases in which 
mitral murmurs exist, a comparison of the aortic and pulmonic sound is 
of great practical value. But the circumstances which may stand in the 
way of this application of auscultation are to be borne in mind. The two 
sounds cannot be compared with reference to mitral, more than with refer- 
ence to aortic lesions, if there be coexisting pulmonary disease, nor when- 
ever the normal relation of the aorta and pulmonary artery to the thoracic 
walls is altered by either past or present disease of lungs, by deformity of 
the chest, or any other cause. It is also to be recollected that mere enlarge- 
ment of the heart may disturb the normal relation of these vessels to the 
walls of the chest. This application, moreover, cannot be made when 
mitral and aortic lesions coexist. Under the latter circumstances it is, of 
course, difficult or impossible to determine how far an existing disparity 
between the aortic and pulmonic sound is due to the aortic, and how far to 
the mitral lesions. 

Another important point pertaining to a mitral systolic murmur is, its 
occurrence without any appreciable lesions. A truly mitral regurgitant 
murmur doubtless always involves lesions of some kind, for it is hardly 
probable that the papillary muscles, as has been supposed, may become 
spasmodically affected and thus give rise to insufficiency or regurgitation 
as a temporary functional disorder. But it is undoubtedly true that a sys- 
tolic murmur either limited to, or having its maximum of intensity near 
the apex, has been repeatedly observed in cases in which mitral lesions 
were not apparent after death. Dr. Bristowe in a paper contained in the 
Brit, and For. 3Ied. Chir. Review, for July, 1861, details six cases of this 
description. Dr. Barlow, in an article in Guy^s Hospital Reports, vol. v., 
1859, states that a mitral murmur may occur (for what reason he does 
not state) in long-continued capillary bronchitis. I have met with some 
instances in which a systolic murmur, supposed to be mitral, existed, and 
no mitral lesions were found after death. 

Case 1.* In the winter of 1859-60, 1 saw a female patient in the Charity 
Hospital, New Orleans, in the service of my colleague, Prof. Brickell, 
affected with capillary bronchitis. After several days there was improve- 
ment as regards the pulmonary symptoms, and then, for the first time, a 
s3'stolic cardiac murmur was discovered. The murmur was loudest at the 
epigastrium, but heard over the site of the apex, and extended to, but not 
above the base of the heart. The patient subsequently died. On exami- 
nation after death the lungs were emphysematous ; there were no valvular 
lesions, all the valves appearing to be sound. The foramen ovale was 
closed. There were no clots. The right ventricle was distended with 
liquid blood. The walls of the heart were of normal thickness. The 
valves and orifices were not measured, nor was the water test of valvular 
sufficiency employed. 

^ Private Records, vol. xi. p. 36. 



46 



Flint, Cardiac Murmurs. 



[Jaly 



In recording this case I have commented on the murmur as follows : 
"What could have caused the loud systolic murmur? I cannot say unless 
it was due to distension of the right ventricle and tricuspid regurgitation." 

In support of the supposition that the murmur was tricuspid, not mitral, 
it is to be noted that the greatest intensity was at the epigastrium. It 
was, however, considered to be a mitral systolic murmur during life. 

Case 2.* During the winter of 1860-61, a patient was under my obser- 
vation in the Charity Hospital, New Orleans, for four months, affected with 
albuminuria and general dropsy. During all this time there was a mitral 
systolic murmur heard at the apex and over the body of the heart, and not 
propagated without the apex. It was regarded as a mitral systolic, non- 
regurgitant or intra-ventricular murmur, and as such pointed out to several 
private classes in auscultation. The patient died by asthenia, and was found 
to have fatty kidneys and cirrhosis of the liver. On examination of the 
heart, post mortem, nothing abnormal was found except some enlargement, 
the organ weighing 12 oz., and a little separation of the marginal extremity 
of two of the aortic segments. The mitral valve appeared to be perfectly 
normal. I expected to find some roughening of the mitral valve but no 
insufficiency; there was, how^ever, no atheromatous, calcareous or other 
deposit, and the valve seemed to be sufficient. There was no aortic, nor 
pulmonic murmur in this case, a fact which excludes the supposition that 
the existing murmur was due to the condition of the blood. 

Case 3.^ During the winter of 1860-61, a patient was under my obser- 
vation in the Charity Hospital, New Orleans, for about six weeks, affected 
with chronic bronchitis and emphysema of lungs. He presented habitual 
dyspnoea which was at times excessive, persisting lividity and anasarca. 
The heart was evidently somewhat enlarged. There was a loud rough 
systolic murmur, having its maximum of intensity at the apex propagated 
without the apex (the record does not state how far), and over the body 
of the heart. On examination after death the volume of the heart was 
not much increased, and its weight was 13 oz. The left ventricle was not 
dilated and the left auricle was small. The walls of the left ventricle did 
not exceed half an inch in thickness, and the appearance of the muscular 
tissue was healthy. The mitral valve was perfectly normal. The orifice 
was not enlarged, and the valve must have been sufficient. No lesion at 
the aortic orifice. The right cavities were much dilated. They were twice 
as large as the left cavities. The walls of the right ventricle were much 
thickened, the thickness falling but little short of that of the left ventricle. 
No lesion of the pulmonic orifice. The tricuspid valve was normal. The 
orifice was very large, admitting the extremities of all the fingers. I have 
appended to the record of this case the following comment : "Whence thfe 
murmur supposed to be a mitral regurgitant? I suspect it was a tricuspid 
regurgitant." 

Dr. Bristowe, in the article already referred to, discusses several conditions 
which have been supposed to give rise to the murmur in cases like those 
which have just been given, viz., clots in the ventricular cavity, spasm of 
the papillary muscles, and enlargement of the auricular orifice so as to 



' Private Records, vol. xi. p. 243. 
^ Hospital Records, vol. xv. p. 423. 



1862.] 



Flint, Cardiac Murmurs. 



47 



render the valve insufficient. His own opinion is tliat the murmur is due 
to a " disproportion between the size of the ventricular cavity and the length 
of the chordas tendinae and musculi papillares." This disproportion he 
attributes to dilatation of the cavity of the ventricle. He also accepts to 
some extent an explanation offered by Dr. Hare, viz., that the murmur 
may be due to a "lateral displacement of the origins of the musculi papil- 
lares in consequence of the rounded form which dilatation imparts to the 
heart." 

These several explanations may each be applicable to certain cases, but 
none of them, apparently, to the cases which I have given. Clots in the left 
ventricular cavity were not present in either of' the cases ; the murmur con- 
tinued too long and too persistently to be due to spasm ; the mitral orifice 
was not dilated, and the enlargement of the heart was not sufficient to occa- 
sion a notable disproportion between the length of the tendinous cords and 
papillary muscles, and the ventricular cavity. I am disposed to think that in 
each of the three cases the murmur was erroneously considered to be mitral ; 
that it was a tricuspid regurgitant murmur. As I have already said, I have 
but little practical knowledge of tricuspid murmurs. I have met with two 
instances in which murmur was connected with well-marked tricuspid lesions 
as verified by examination after death. In both these cases the murmur 
was heard over the body of the heart, within the superficial cardiac region. 
I suspect that a tricuspid regurgitant murmur is not so rare as is generally 
supposed, and that not very infrequently it is <?onsidered to be mitral. This 
opinion is expressed by Dr. Gairdner in an interesting article on cardiac 
murmurs in the Edinburgh Med. Monthly, Nov. 1861. According to this 
able clinical observer, a tricuspid systolic murmur is heard over the right 
ventricle where it is uncovered of lung, being but slightly audible above 
the third rib ; and, if the heart be much enlarged, it may be heard louder 
towards the xiphoid cartilage. A collection of clinical facts respecting the 
frequency of tricuspid murmurs, the physical conditions giving rise to them, 
and the means of discriminating them from mitral murmurs, is an important 
desideratum. 

Mitral direct murmur. — This murmur is not recognized by many aus- 
cultators, and its existence is denied by some. It is generally confounded 
with a mitral systolic murmur. For many years after I had begun to devote 
special attention to cardiac affections, I committed this mistake, and I was 
sometimes puzzled to account for a supposed mitral systolic murmur rough 
at its beginning and soft at its ending. In my records of some cases before 
I had learned to separate the mitral direct from a mitral regurgitant, I 
have described the latter as presenting the variation just stated, the fact 
being that the two murmurs were present, the one rough and the other 
soft. It is only within the last few years that I have discriminated these 
two murmurs, but during this time my field of clinical observation has 



48 



Flint, Cardiac Murmurs. 



[July 



been so extensive that I have had abundant opportunities to make the dis- 
crimination. With regard to the frequency of the mitral direct murmur, 
it is by no means so rare as is generally supposed, and as I had thought 
some yeairs ago. At one time during the past winter, in Bellevue Hospital, 
I knew of six examples of it, and several also at the Blackwell's Island 
Hospital. When the auscultator has learned to distinguish it, he will not 
be long in finding it if he be in the way of seeing a moderate number of 
cases of disease of the heart. From what has now been said, it is obvious 
that an important point pertaining to this murmur is, its discrimination 
from other murmurs. This point will first claim consideration. 

In order to comprehend this murmur, it is essential to understand clearly 
when the mitral direct current of blood takes place. The opportunity of 
observing the movements of the heart exposed to view in a living animal, 
conduces greatly to a clear understanding of this point. The mitral direct 
current is produced by the contraction of the auricles ; now, when do the 
auricles contract ? When the movements of the heart are observed, it is 
seen that the contraction of the auricles immediately precedes the contrac- 
tion of the ventricles. So close is the connection between the contraction 
of the auricles and the contraction of the ventricles, that the former appears 
to merge into the latter; there is no appreciable interval between the two, but 
the successive movements, although distinct, appear to be continuous. More- 
over, it is evident to the eye, and to the touch, that the contractions of the 
auricles are not so feeble as some seem to suppose. The mitral direct cur- 
rent of blood, therefore, occurs just before the ventricular systole ; it con- 
tinues up to the ventricular systole, and must, of course, instantly cease 
when the ventricles contract. The contraction of the ventricles causing 
the first sound of the heart, it follows that the mitral direct current caused 
by the auricular contractions must take place just before the first sound ; 
that it must continue to the first sound, and that it cannot continue an 
instant after the first sound. 

The mitral direct murmur is produced by the mitral direct current of 
blood forced by the auricular contractions through a contracted or rough- 
ened mitral orifice. Hence, the facts just stated with regard to the current, 
apply to the murmur. The murmur occurs just before the ventricular sys- 
tole or the first sound of the heart ; it continues up to the occurrence of 
the first sound, and instantly ceases when the first sound is heard. It is 
not strictly correct to call this a diastolic murmur ; it does not accompany 
the second or diastolic sound of the heart. The aortic regurgitant is the 
only true diastolic murmur. The mitral direct is a pre-systolic murmur ; 
this name expresses its proper relation to the heart sounds, and it is the 
only murmur which does occur in that particular relation. The time of its 
occurrence as just explained, and as expressed by the term pre-systolic, is 
sufficient for its easy recognition when once it is fully comprehended. 
Although, when this murmur is fully comprehended, and has been repeatedly 



1862.] 



Flint, Cardiac Murmurs. 



49 



verified, it is more readily recognized than either of the other murmurs, 
there is often at first considerable difficulty in determining its existence. 
Let me endeavour to point out the way in which it may be ascertained. I 
have already said that by those who overlook this murmur it is generally 
confounded with the mitral systolic or regurgitant murmur. This is in 
consequence of its close connection with the first sound, and because it 
is heard at and near the apex of the heart. Now it is evident that a mitral 
systolic murmur cannot commence before the ventricular systole. It is 
equally evident that the ventricular systole and the first sound of the heart 
are synchronous. It is, therefore, an absurdity to suppose that a mitral 
systolic or regurgitant murmur can be pre-systolic in the time of its occur- 
rence. This murmur must necessarily accompany and follow the first sound 
of the heart, as clinical observation has established. We have, then, only 
to determine that a murmur is pre-systolic, and that it does not accompany 
the second sound of the heart (z. e., there is an appreciable interval of time 
between the second sound and the murmur), to recognize it as a mitral 
direct murmur. Generally it is sufficiently easy, after a little practice, to 
perceive that the murmur precedes the sound, but, if there be difficulty or 
doubt, there is a ready mode of rendering it apparent ; this Is by placing 
the finger on the carotid pulse. The carotid pulse is synchronous with the 
first sound of the heart, or, at least, so nearly synchronous, that there is 
no appreciable interval of time between them. Placing, then, the finger 
on the carotid and listening to the murmur at the apex, the murmur is 
found to occur before the arterial impulse and to cease instantly when the 
latter is felt. 

The mitral direct murmur is to be discriminated from an aortic regurgi- 
tant murmur. These two murmurs may be confounded at first, but after 
a little practice the discrimination is easy. The aortic regurgitant murmur 
accompanies and follows the second sound of the heart. The mitral direct 
commences after the second sound. Generally there is a distinctly appre- 
ciable interval of time between the second sound and the commencement 
of the murmur. The aortic regurgitant murmur may be prolonged nearly 
or quite through the long pause up to the first sound ; but the intensity of 
the murmur diminishes with the prolongation, the murmur being insensibly 
lost before or when the first sound occurs. The mitral direct murmur, on 
the contrary, always continues up to the first sound, and instead of losing 
any of its intensity, it becomes more intense, and appears to be abruptly 
arrested, in its greatest intensity, when the first sound occurs. This is a 
striking characteristic. The difference in the situation in which two mur- 
murs respectively are heard with their maximum of intensity, is another 
point in the discrimination. The aortic regurgitant murmur is generally - 
heard at the base of the heart, and is heard loudest a little below the base 
near the left margin of the sternum on a level with the third intercostal 
space. The mitral direct murmur is heard loudest at or a little within the 
No. LXXXYII July 1862. 4 



50 



Flint, Cardiac Murmurs. 



apex ; is generally confined within a circumscribed space, not propagated 
much without the apex and rarely to the base of the heart. 

The quality of the mitral direct murmur is, in many cases, characteristic. 
In my work on diseases of the heart I have said that this murmur is gene- 
rally soft. My experience since that work was written has shown me that 
this statement is incorrect. The murmur is oftener rough than soft. The 
roughness is often peculiar. It is a blubbering sound, resembling that pro- 
duced by throwing the lips or the tongue into vibration with the breath in 
expiration. I suppose that the murmur is caused, in these cases, by the 
vibration of the mitral curtains, and that the vibration of the lips or tongue 
by the breath represents the mechanism of the murmur as well as imitates 
the character of the sound. At one time I supposed this blubbering mur- 
mur denoted a particular lesion, viz., adhesion of the mitral curtains at 
their sides, forming that species of mitral contraction known as the button- 
hole slit; but I have found this variety of murmur to occur without that 
lesion, and, in fact, as will be seen presently, when no mitral lesion whatever 
exists. 

A mitral direct murmur may, or may not, be associated with a mitral 
systolic murmur. Without having analyzed the numerous examples which 
I have recorded during the last few years, I should say that, while the 
mitral systolic murmur is much more frequent in its occurrence than the 
mitral direct, the former, indeed, being the most common of all the mur- 
murs, the mitral direct is observed quite as often without, as with the 
mitral systolic. But the two frequently coexist, and then the demonstra- 
tion of the existence of the mitral direct murmur may be made more striking 
than when it exists alone, provided, as is usually the case, this murmur be 
rough and the mitral systolic murmur be soft. Listening at or near the 
apex in a case presenting a blubbering mitral direct and a soft mitral sys- 
tolic murmur, the former, of course, precedes the latter, and between the 
two occurs the first sound of the heart, the apex-beat and the carotid pulse. 
The first sound, the apex beat or the carotid pulse will be found to mark 
the abrupt ending of the mitral direct, and the beginning of the mitral 
systolic murmur. The different relations of the two murmurs to the first 
sound are distinctly perceived in such a case if the observer be prepared to 
perceive them by a clear comprehension of the subject. And when once 
the discrimination between the two murmurs has been fairly made, it be- 
comes sufficiently easy; indeed, the mitral direct murmur is then more 
readily recognized than either of the other murmurs. 

The existence of a mitral direct murmur has been theoretically denied 
on the ground that the auricular contractions are too weak to propel the 
current of blood with sufficient force to give rise to a sound. It is un- 
doubtedly true that, other things being equal, the intensity of a murmuir 
is proportionate to the force of the current, and clinical observation shows 
that sometimes a murmur is not appreciable when the heart is acting feebly, 



1862.] 



Flint, Cardiac Murmurs. 



51 



but becomes distinct when the power of the heart's action is from any 
cause increased. But murmurs do by no means always require for the 
production a powerful action of the heart ; on the contrary, loud murmurs 
are often found when the heart is acting very feebly. For example, I have 
reported a case in which an aortic direct and an aortic regurgitant murmur 
were well marked in a patient an hour before death, the patient dying from 
paralysis of the heart due to distension of the left ventricle. Yenous mur- 
murs in the neck are often notably loud when, assuredly, the force of the 
current of blood in these veins is vastly less than the current from the 
auricles to the ventricles. The feebleness of the current in this instance is 
shown by the slight pressure requisite to interrupt it and arrest the murmur. 
It requires but little force of the expiratory current of air to throw the 
lips into vibration so as to produce a loud sound. Moreover, one has only 
to see and feel the contractions of the auricle, when the heart is exposed 
in a living animal (the heart's action being much weakened under these 
circumstances) to be convinced that the power of these contractions is not 
so small as some seem to imagine ; the blood is driven into the ventricles 
with considerable force. It is hardly necessary to say, however, that d 
priori reasoning with regard to the existence or non-existence of physical 
signs is not admissible. Their existence is a matter to be determined by 
direct observation. Clinical observation shows that a murmur does occur 
at the precise time when the mitral direct current takes place as shown by 
observation of the movements of the heart exposed to view in a living 
animal. And clinical observation shows that this murmur is not always 
feeble, but, on the contrary, is not infrequently notably loud. 

So much for the reality of the mitral direct murmur and the means of 
discriminating it from other murmurs. It remains to consider another 
important practical point, viz., the pathological import of this murmur. 
As already stated, it is developed in connection with a contracted mitral 
orifice, and, so far as my experience goes, especially in connection with con- 
traction caused by adherence of the mitral curtains, forming the buttonhole 
slit; the murmur, then, being due, not to the passage of blood over a rough- 
ened surface, but to the vibration of the curtains. And the sound, as thus 
produced, is peculiar, resembling the sound which may be produced, in an 
analogous manner, by causing the lips to vibrate with an expiratory pulf. 
The murmur, however, may be produced by the flowing of the current of 
blood over a roughened surface, without contraction of the aperture. This 
is undoubtedly rare. As a rule, the force of the mitral direct current is 
not sufficient' to develop a murmur unless there be mitral contraction. Is 
this murmur ever produced without any mitral lesions ? One would d pri- 
ori suppose the answer to this question to be in the negative. Clinical 
observation, however, shows that the question is to be answered in the 
affirmative. I have met with two cases in which a well-marked mitral direct 
murmur existed, and after death in one of the cases no mitral lesions were 



52 



Flint, Cardiac Murmurs. 



[July 



found; in tlie other case the lesion was insignificant. I will proceed to 
give an account of these cases, and then endeavor to explain the occurrence 
of the murmur. 

Case 1.^ In May, 1860, I examined a patient, aged 56, who had had 
repeated attacks of palpitation, sense of suffocation, with expectoration of 
bloody mucus and a feeling of impending dissolution, but without pain, the 
paroxysms resembling angina, excepting the absence of pain. In the inter- 
vals between these attacks he was free from palpitation, did not suffer from 
want of breath on active exercise, and considered himself in good health. 
He had never had rheumatism. On examination of the chest, the heart 
w^as found to be enlarged, the enlargement being evidently by hypertrophy. 
At the apex was a pre-systolic blubbering murmur, which I then supposed to 
be characteristic of the button -hole contraction of the mitral orifice. At 
the base of the heart was an aortic regurgitant murmur, which was diffused 
over nearly the whole prsecordia. There was no systolic murmur at the 
base or apex. Three days after this examination the patient was attacked 
with another paroxysm, and died in a few moments after the attack, sitting 
in his chair. The heart was enlarged, weighing 16 J oz., the walls of the 
left ventricle measuring |ths of an inch. The aorta was atheromatous, and 
dilated so as to render the valvular segments evidently insufficient. The 
mitral valve presented nothing abnormal, save a few small vegetations at 
the base of the curtains, as seen from the auricular aspect of the orifice. 

In this case it is assumed that the mitral direct murmur, which was loud 
and of the blubbering character, was not due to the minute vegetations 
which were found after death. There was no mitral contraction. The 
mitral valve was unimpaired, so that the murmur could not have been due 
-to mitral regurgitation. 

Case 2.^ In February, 1861, I was requested to determine the murmur 
in a case at the Charity Hospital, New Orleans. I found an aortic direct 
and an aortic regurgitant murmur, both murmurs being well marked. There 
was also a distinct pre-systolic murmur within the apex, having the blubber- 
ing character. On examination after death, the aorta was dilated and 
roughened with atheroma and calcareous deposit. The aortic segments 
were contracted, and evidently insufficient. The mitral curtains presented 
no lesions; the mitral orifice was neither contracted nor dilated, and the 
valve was evidently sufficient. The heart was considerably enlarged, weigh- 
ing 17|- oz., and the walls of the left ventricle were an inch in thickness. 

In the second, as in the first of the foregoing cases, it is evident that a 
mitral systolic murmur was not mistaken for a mitral direct murmur, for in 
both cases, the conditions for a mitral systolic murmur were not present. 
In both cases the mitral direct murmur was loud and had that character of 
sound which I suppose to be due to vibration of the mitral curtains. In 
both cases, it will be observed, an aortic regurgitant murmur existed, and 
aortic insufficiency was found to exist post mortem. How is the occurrence 
of the mitral direct murmur in these cases to be explained? I shall give 
an explanation which is to my mind satisfactory. 



' Private Records, vol. x. p. 713. 



2 Ibid., vol. xi. p. 241. 



1862.] 



Flint, Cardiac Murmurs. 



53 



The explanation involves a point connected with the physiological action 
of the auricular valves. Experiments show that when the ventricles are 
filled with a liquid, the valvular curtains are floated away from the ventri- 
cular sides, approximating to each other and tending to closure of the 
auricular orifice. In fact, as first shown by Drs. Baumgarten and Hamer- 
nik, of Germany, a forcible injection of liquid into the left ventricle through 
the auricular opening will cause a complete closure of this opening by the 
coaptation of the mitral curtains, so that these authors contend that the 
natural closure of the auricular orifices is effected, not by the contraction of 
the ventricles, but by the forcible current of blood propelled into the ventri- 
cles by the auricles. However this may be, that the mitral curtains are 
floated out and brought into apposition to each other by simply distending 
the ventricular cavity with liquid, is a fact sufficiently established and easily 
verified. ISTow in cases of considerable aortic insufficiency, the left ventricle 
is rapidly filled with blood flowing back from the aorta as well as from the 
auricle, before the auricular contraction takes place. The distension of the 
ventricle is such that the mitral curtains are brought into coaptation, and 
when the auricular contraction takes place the mitral direct current passing 
between the curtains throws them into vibration and gives rise to the cha- 
racteristic blubbering murmur. The physical condition is in effect analogous 
to contraction of the mitral orifice from an adhesion of the curtains at their 
sides, the latter condition, as clinical observation abundantly proves, giving 
rise to a mitral direct murmur of a similar character. 

A mitral direct murmur, then, may exist without mitral contraction and 
without any mitral lesions, provided there be aortic lesions involving con- 
siderable aortic regurgitation. This murmur by no means accompanies 
aortic regurgitant lesions as a rule; we meet with an aortic regurgitant 
murmur frequently when not accompanied by the mitral direct murmur. 
The circumstances which may be required to develop, functionally, the latter 
murmur, in addition to the amount of aortic regurgitation, remain to be 
ascertained. Probably enlargement of the left ventricle is one condition. 
The practical conclusion to be drawn from the two cases which have been 
given is, that a mitral direct murmur in a case presenting an aortic regur- 
gitant murmur and cardiac enlargement, is not positive proof of the exist- 
ence of mitral contraction or of any mitral lesions. The coexistence of a 
murmur denoting mitral regurgitation, in such a case, should be considered 
as rendering it probable that the mitral direct murmur is due to contraction 
or other lesions, and not functional. 

Dr. Gairdner, in a recent article already referred to, proposes a change 
of name for the mitral direct murmur. He proposes to call it an auricular 
systolic murmur. Inasmuch as the murmur is produced by the systole of 
the left auricle, this name is significant. And the usual name is open to 
this criticism, viz. : it is not produced by the whole of the mitral direct 
current, but only that part of the current which is caused by the contraction 



54 



Dickson, Smallpox. 



[July 



or systole of the auricle. From the situation of the auricles as regards the 
ventricles, the former being placed above the latter, and the free communi- 
cation by means of the auriculo-ventricular openings, the blood must begin 
to flow from the auricles into the ventricles the instant the ventricular con- 
tractions cease. During the first part of the long pause or interval of 
silence, i. e., the period after the second sound and before the subsequent 
first sound of the heart, the blood flows from the auricles into the ventricles 
simply in obedience to gravitation. It is not ascertained that this part of 
the current ever gives rise to a murmur. If it does, the murmur would 
follow immediately the second sound, or when an aortic regurgitant murmur 
occurs. I have conjectured that such a mitral direct murmur may occur, 
and that it is confounded with an aortic regurgitant murmur. This con- 
jecture is based on cases in which an apparent aortic regurgitant murmur 
existed, and the aortic valves seemed to be nearly or quite sufi&cient on 
examination after death. However this may be, the mitral direct current 
giving rise to the murmur which has been considered in this article, is not 
the current which immediately follows the second sound, and is due to gra- 
vitation alone, but it is the current immediately preceding the ventricular 
systole, and due to the systole of the auricle. Hence, as it seems to me, 
the name proposed by Dr. Gairdner, being more specific and accurate, is to 
be preferred to that in common use. 



Art. III. — On Smallpox, and the Means of Pr^otection against it. By 
S. Henry Dickson, M. D., Professor of the Practice of Medicine in 
Jefferson Medical College, Philadelphia, 

The exanthemata may fairly claim a high place among the topics of 
greatest and most constant interest to the medical practitioner. They 
seem to solicit attention by their marked and impressive features ; and 
present so many palpable, well-defined, objective phenomena, that we feel 
always as if on the point of receiving some clear and instructive develop- 
ments from the study of the facts observed in their history and progress. 
At first sight their origin appears to be plainly traceable, their diagnosis 
distinct and easy, their nature obvious. But a closer examination will soon 
convince us that our knowledge of them is by no means so satisfactory as 
we had imagined, and that the field is still open for further and more 
minute exploration. 

Three of the class of diseases to which the name has been attached ex- 
hibit in common certain striking characteristics, exclusively their own, and 
therefore well deserve to be set apart from all others, and arranged together. 
Smallpox, scarlatina, and measles are all of them eruptive affections, py- 



1862.] 



Dickson, Smallpox. 



55 



rectic, contagious, self-limiting, and self-protective. They stand alone as 
to the concurrence of these conditions, one or more of which may belong 
to certain maladies, but all of them to none beside. Thus, hooping-cough, 
with no cutaneous eruption, is pyrectic, contagious, self-protective, and 
somewhat vaguely self-limiting. Dengue is irregularly eruptive as to con- 
stancy, characteristic appearance, and periods, though contagious and pro- 
bably self-protective. Erysipelas is neither self-limiting nor self-protective ; 
and the same negatives are true of varicella. It is perhaps worthy of 
remark in this connection, that all maladies which attack the human sub- 
ject but once, and are in this sense self-protective, have been by various 
authorities regarded, and with some ,show of plausibility, as among the 
exanthemata. Pertussis is so considered by Watt ; typhus and typhoid by 
many pathologists ; Hildebrand ranges yellow fever thus in the catalogue, 
and several of our American brethren have confounded it with dengue, 
which has vastly better, though still insufficient, claims to that position. 

The well-arranged, carefully prepared, and valuable " Report on Meteor- 
ology and Epidemics for 1861," read by Dr. Jewell before the College of 
Physicians of Philadelphia on the 5th of February, 1862, and published in 
the last (April) number of this Journal, contains some appalling statements 
in reference to the three pestilential affections there exclusively denominated 
exanthems. We learn from it that in the city of Philadelphia, containing 
568,034 inhabitants, there died within twelve months from smallpox 158 
persons; from scarlatina 1190 ; and from measles (of which it should be 
recollected that the fatal results are in great proportion indirect and masked 
under other names) 14. With most commendable industry, and with an 
intelligent zeal which entitles him to the thanks and highest respect of our 
profession. Dr. Jewell has collated, tabularly and otherwise, a large mass 
of useful facts and observations, in addition to the mere statistics of his 
report. Going back to 180T, he places before us a comparative view of 
the annual mortality of the most loathsome and destructive among them. 
We find it recorded of smallpox, which has figured largely in the bills of 
mortality for several years past, that the next highest number of deaths 
took place in 1852, 421 ; in 1856, 390 ; in 1824, 325. This terrible pes- 
tilence was, last year, about twice as fatal as at any time during the current 
century, with the exception of the year 1852, when the difference, 331, was 
not far below the greatest amount of mortality in the worst other year of 
the century. We cannot avoid being shocked at this retrograde exhibition, 
and shrinking from the acknowledgment of professional failure and defeat 
which it seems to imply. We are apt to take for granted — nay, I will 
maintain it to be positively true— that, fatal as this disease is even now, its 
proportional mortality has been vastly reduced. Fewer of those attacked 
die of it than formerly by a great difference, and we have occasion to notice 
much less deformity and mutilation by it. Allowing, then, for this dimin- 
ished violence and destructiveness, we contemplate with horror the im- 



56 



Dickson, Smallpox. 



[July 



mense mass of suffering which must in this community have overwhelmed 
the multitudes of miserable sick who passed through its wretched stages 
of varying infliction, recovering finally ; many of them, doubtless, through 
tortures far worse than death itself. If we carry out our thoughts to the 
soldiers of the great armies now in the field, and the camp followers, and 
attendants, and refugees of all sorts, upon whom this scourge is widely and 
heavily laid, we shall shudder with quivering sympathy, and painfully lament 
the woes of our frail and afflicted race. And yet farther ; when we reflect that 
all these horrors were preventible, and ought to have been prevented, our 
sympathy will be freely mingled with shame and remorse ; shame, that in 
the light of advancing civilization, governments and law-makers should 
not have accepted, instituted, and enforced the proper means of preserva- 
tion from such evil ; and remorse at our remissness as a professional body, 
intrusted with the care of the physical well-being of our fellow-men, in 
not having urged, with unceasing and irresistible importunity, measures at 
once so important and so feasible. Dr. Jewell quotes and adopts the re- 
mark of an English writer, " that the absence of an efficient system of 
protection should be considered a national disgrace ; almost a national 
crime and we must all acquiesce in and feel deeply the truth of the im- 
putation. 

I have read with much pleasure the observations made by Dr. Nebinger 
before the Philadelphia County Medical Society, on the 13th of ^^ovember, 
1861, on the subject of this essay, and given to the public in the Fhil. 
3Ied. and Surg. Reporter, of March 29, 1862. I have already stated my 
accordance in his opinion that smallpox is better treated, and more suc- 
cessfully, now than in the days of Sydenham. During a long course of 
practice, I have myself lost so small a proportion of my variolous patients, 
that I am fully prepared to accept the favourable view he presented of his 
own good fortune. The data he then offered will assist us to estimate — 
approximately — the number of sick who suffered, but did not die. This is 
an essential element to a fair appreciation of the real value of prevention. 
I have always considered it a matter of great regret that we have no re- 
cord of the extent of actually existing disease; its frequency; its dura- 
tion ; its degree ; its calamitous privations and inflictions. Such a register 
is a necessary complement to the bare ''bills of mortality," useful and 
instructive as these have become in the hands of Dr. Jewell and his colla- 
borators. 

Dr. Nebinger had seen more than 30 cases : he had among them 5 con- 
fluent ; but one death occurred from them all. He ascribed this large 
success to his energetic efforts to sustain the strength of his patients dur- 
ing the progressive stages of maturation, suppuration, desquamation, and 
redintegration of cutis. 

In a report prepared by Drs. Bell and Mitchell, of this city, we have a 
table of 248 cases given, of which 89 died — in the epidemic of 1823-24. 



1862.] 



Dickson, Smallpox. 



61 



I saw smallpox prevailing extensively in New York during 1848 and 
1849. Many of the members of the medical class in the University in 
which I then held the chair of the Practice of Physic, were attacked ; of 
these, 50 or more in number, only 2 died. Averaging these three state- 
ments, each of which is extreme, two of them in good fortune, and one in 
the reverse, we have 1 death in about 3 J cases, reaching a total of 2653 
sick. 

Gregory estimates the average mortality all over the world as 1 in 6. 
In Dr. John Davy's Notes and Observations on the Ionian Islands and 
Malta, there is an interesting history of "the Variolous Epidemic of 
1830-31, in Malta." The deaths were llt2 out of 806Y cases reported ; 
" many cases occurred which were not reported ; of the mildest kind, pro- 
bably." These proportions would give us about 5000 cases of smallpox 
in one year in this favoured city. If we take from the very happy rate of 
success announced by Dr. Nebinger, fully two-thirds — and we should re- 
member that both Drs. Burns and Remington ''fully agreed with him, and 
added their testimony as to the good results of his mode of treatment" — if 
we admit, I say, that Dr. N. was singularly fortunate, and subtract two- 
thirds as approaching the more general average, making the deaths 1 in 10 
of the whole aggregate of cases, we shall find our sick amounting to 1580. 
What an accumulation of anguish ! What an infinite sum of wretched- 
ness ! Pew of them could have been ill a shorter time than a week, in 
greater or less degree ; at least half of them would be in an invalid con- 
dition, and in a state of feeble convalescence for two and three weeks, many 
even more than this ; and although two-thirds of them were young chil- 
dren, yet they would require, each of them, an adult attendant. Putting 
the average duration of illness, then, at ten days, 15,800 days of useful 
life would be lost to the individuals ; of ordinary labour to the community 
— more than two hundred years of privation, suffering, and sorrow ! 

This calculation would be irrelevant and useless, if we were treating of 
an inevitable form of calamity; but I hold the contrary to be positive truth 
here. I believe it to be in the power of all civilized and well governed 
communities to confine within very narrow limits, or rather to exterminate 
the pestilence under discussion. I contend that it is their bounden duty to 
set about this purpose at once and without delay, and to press the effort 
with energetic constancy. It is hardly requisite, I presume, that I should 
explain my meaning in the use of the words ''extermination" and "extir- 
pation." I surely have not conceived the idea of physical annihilation of 
the virus of smallpox, or the disease variola, ontologically or dynamically 
considered. What I intend and aim at is its extinction as an epidemic, as 
a pestilence; its obliteration from the bills of mortality. It will be seen 
that the course which I am about to propose with this view implies the 
constant employment, and of course the preservation of smallpox matter, 
as we now keep up and preserve the vaccine. It may happen, which 



58 



Dickson, Smallpox. 



[July 



Heaven grant ! that this dreaded virus may hereafter become difficult to 
procure, and a supply will need to be sought out of the bounds of civiliza- 
tion and well-ordered governments. Such a supply will always doubtless 
be within reach, among the barbarous hordes of Africa, Asia, and South 
America. 

But if we may trust in familiar observation and repeated tabular state- 
ments, we are possessed of means of defence against the spread of this 
repulsive malady, and also against its fatal violence, which may be made 
available to an extent as yet matter only of reasonable calculation and 
hopeful estimate. Very few deaths proportionally or absolutely occur from 
inoculated smallpox ; very few from smallpox after vaccination : it will 
be seen that I would combine universally and regularly the modifying 
and palliative influences of the two, by inoculation superimposed upon 
vaccination. In two out of three cases hereafter referred to, the result of 
such inoculation was "local affection without any fever or eruption; in 
the third, local affection without fever, but with papular eruption on the 
seventh day, not advancing to vesicles." It remains to be ascertained 
whether such effects as these would comprise the general history on a great 
scale ; and whether the influence exerted on the constitution would be as 
thoroughly protective as I am disposed to anticipate. Should there be no 
disappointment in these respects, surely it is not visionary to hope for as 
few deaths from smallpox in the next generation as now from vaccine. 

The majority, even of my professional brethren, may perhaps continue 
to think that I exaggerate the competency of the means proposed : yet no 
one will doubt or deny that much, very much of what is contemplated, 
may be done by their vigorous and unremitting application. In order 
properly to appreciate, however, the value and probable efficacy of our 
means of restriction, prevention, and extirpation, we must carefully con- 
sider the modes of origin and propagation of the disease we are to contend 
with. 

1. D©es variola ever arise spontaneously, or from ordinary contingencies, 
or under any known or suggested circumstances of defective or vicious 
hygiene ? 

2. Does it arise from degradation or intensification of any other known 
forms of disease, which may themselves originate spontaneously or acci- 
dentally? Or, 

3. Does it always require a specific infection, an implantation, or efficient 
impression from a previous case fully and characteristically developed? 
There are no other imaginable alternatives, I believe ; and it is not easy 
to obtain an answer perfectly satisfactory to either of the above questions, 
although we may reach a fair practical result. 

1. I will not venture to deny the possibility of "spontaneous generation" 
of smallpox. It came into existence once, and therefore logically may again 
occur, provided the same conditions coincide again to produce it. Nor am 



1862.] 



Dickson, Smallpox. 



59 



I unaware that there are several instances on record, in which the breaking 
out of the disease has been totally unaccountable. Nay, I hare myself met 
with and published a history of one of the strongest and strangest among 
the cases that have been observed. I need not say that such rare facts 
ought to be studied with the admission that our knowledge of the entire 
range of details must always be incomplete, and that it will be safest and 
most reasonable to follow the patent and obvious course of known ana- 
logies in forming our opinions. Ordinary pollutions of the atmosphere 
produce their known effects ; none have been defined or even conjectured 
of a nature causative of variola. It is easy to enumerate and imagine 
obscure and extremely varied modes of its infectious communication wher- 
ever social and commercial intercourse obtains. "We know the tenacity of 
its contagion, and shall treat of its great diversity of vehicles. We have 
no account of its outbreak where such conveyance was not demonstrably 
possible at least ; and if possible, it at once becomes more probable and 
presumable than the vague hypothesis of "spontaneous generation." Be- 
sides this, speaking practically, such instances will be amenable to the same 
methods of prevention that will affect, as we hope, all the others, and even 
in special degree. For there is no alleged example, among all these strange 
seizures, of persons protected, either by vaccination or previous attack, 
having been the subjects of obscure invasion. These yield only to the more 
vehement impressions of obvious and definite exposure. 

2. The second inquiry presents some intrinsic difficulties, and is not 
readily disposed of. We might at once cut the Gordian knot, and pro- 
nounce dogmatically with Copeland and Gregory that "the whole confusion 
arises from mistaken diagnosis but I will not think or speak thus lightly 
of the observations and opinions of such men as Howitz and Bateman, 
and Hennen and Thomson. The very authorities above quoted admit 
"that there is a form of smallpox w^hich may be mistaken for varicella;" 
Gregory makes indeed a class of "varicelloid cases." The true question is 
whether or not they actually run into each other, and are capable of mutual 
generation. Of the difficulty of clearly distinguishing them, every prac- 
titioner should be cautiously aware. Dr. Davy tells us of the Maltese 
epidemic of 1830-31, that "in most instances when the disease occurred 
after vaccination, it was mild and short in its course, often resembling 
chicken-pox rather than smallpox. Chicken-pox was at the same time 
common, ninety-one cases being reported." He regards the diagnosis as 
doubtful, and mentions a case occurring three months after the last report 
of smallpox, which he "thought to be genuine variola, though mild. It 
was among some cases of chicken-pox that it happened." Gregory, dwell- 
ing on the capricious mingling of the severe and slight varieties of small- 
pox, says, "A confluent case shall give origin to a varioloid, and a mild 
distinct, and even a varicelloid case ; and these shall generate in their turn 
malignancy and confluence." 



60 



Dickson, Smallpox. 



[July 



Tlie spontaneity, that is, the independence of any specific sources of pro- 
duction of varicella is universally taken for granted. It has never been 
proved, nor, on the other hand, so far as I know, questioned. Yet it has 
clearly, a very relevant and important bearing upon our main subject. 
Enough has been said to show the danger of error here. ^Nevertheless, 
and in spite of all these warnings, fatal mistakes continue to be made by 
experienced physicians. On three occasions I have known smallpox to 
spread from infection communicated by cases pronounced to be varicella ; 
the first and introducing instances being slight and of mild character, fol- 
lowed by development of marked cases of violence and malignity. I have 
now before me a melancholy ''appeal to the public" of a city into which 
the writer had been the unhappy agent of importation of smallpox, quite 
recently. The disease spread and prevailed epidemically in a very fatal 
form, and he became odious under the imputation, as his printed statement 
expresses it, of "recklessly sowing the seeds of the most contagious and 
loathsome of maladies, by freely mingling with the people while knowing 
that he carried the deadly infection about his person." He affirms that he 
returned home from New York in perfectly sound health ; that being 
attacked a few days after with a slight illness, accompanied by an eruption on 
his face and body, he consulted an "eminent physician," who unhesitatingly 
pronounced the eruption to be chicken-pox, and told him he might resume 
his business without fear. "Nor did the idea of smallpox once cross my 
mind until, after my own child had caught the infection in an aggravated 
form and fallen a victim, the physicians began to whisper the dreaded 
name." 

The preponderance in number of what are called "negative facts," ex- 
amples of innoxious presence and prevalence of varicella, should never be 
allowed to lull our caution to sleep. No prudent practitioner will fail to 
watch attentively the course of chicken-pox in any group or collection of 
unprotected subjects. I do not believe it to be possible to diagnosticate 
from it by any definable marks some of the irregular varioloid affections, 
which yet are potential in spreading smallpox ; and even those who con- 
tend most peremptorily for precise distinctions, allow that we do meet with 
a "confounding" similarity. Where there exists any doubt, we should 
have prompt recourse to the most immediate protective measures. 

Nor must we entirely pretermit the consideration of another possible 
origin or development of smallpox. Its identity with vaccine is at the 
present day the received doctrine with the majority of our profession. I 
will neither affirm nor deny it, but proceed, ex ahundante cautela, to draw 
from it a practical inference. If it be true that vaccine is a modified or 
degenerate variola, altered in its features and history by transmission into 
and through organisms of lower type, it would be difficult to imagine why 
it should not, when restored to its original nidus and pabulum, resume, 
under fostering contingencies, its orif^inal characteristics. Some startling 



1862.] Dickson, Smallpox. 61 

examples have occurred, as not long ago at Richmond, of the introduction of 
smallpox with matter supposed to be vaccine, and the explanation has been 
accepted that an unfortunate accidental mixture of the two contagious 
viruses had taken place. No one now doubts that vaccine may arise spon- 
taneously in the cow; Jenner thought, erroneously, that it depended upon 
an equine affection, "the grease ;" Baron and Ceeley have attempted to 
prove that they are both variolous. And even if with Gregory we dissent 
from their conclusions, and accept with him the views of Greaser, we do 
not escape from reasonable fear of possible danger : if "a, morbid poison 
applied to different animals produces, not a similar and specific disease, but 
the disease to which the animal from constitution and structure is predis- 
posed." ''Equine matter, vaccine lymph, variolous matter — each, when 
applied to the vessels of the cow, develops vaccinia," says Gregory. It 
would be difficult to show, upon this view, why, when applied to the 
vessels of the human subject, they should not develop smallpox. 

And what shall we say of cases in which " there is a general eruption of 
Yaccine Vesicles over the body, resembling, in some patients, those of 
Varicella," as we find it stated in the notes to Gregory's excellent work on 
Eruptive Fevers. To the small number of these hitherto recorded, I will 
add one from the pen of a physician, himself the subject. It is described 
in the following extract of a letter to me from Dr. Henry H. Cone. 

I was inoculated in the year 1815, by Dr. Samuel B. Woodward, of Weathers- 
field, Conn., immediately after having been somewhat exposed to the contagion 
of smallpox. The vaccine matter was inserted in two places, about the middle 
and anterior part of the left arm. At the usual time the genuine symptoms of 
cowpox made their appearance, such as the gradual formation of pustules which 
continued to increase until they had attained the usual size. Along with the 
two pustules, which formed at the places where the virus was inserted, were 
three others on different parts of the body, which were a day or two later, 
according to the best of my recollection. One of these was situated on the 
right arm at its upper and anterior part, forbidding the possibility of its coming 
in contact with or originating in the direct application of the virus ; another 
was situated on the right thigh ; the third on the parietes or surface of the abdo- 
men. The three last mentioned pustules were in no respect different from those 
which formed at the places where the matter was inserted, neither are the 
remaining cicatrices, all of them being marked with small pits or depressions 
near their margins. There was some symptomatic fever ; though not so much 
as to deter me from my ordinary pursuits. 

In two of the instances from Gregory, the matter of the extra pustules 
was experimented with and genuine vaccine resulted. I will confess to 
some apprehension, that in examples of this constitutionally eruptive im- 
pression of vaccine, and especially where the pustules resembled varicella 
more or less, there would be a risk of arousing the ''varioloid predisposi- 
tion" of Gregory and Greaser. A " very curious case" indeed is given in 
the notes above referred to, of a "constitutional vesicle" breaking out at 
a distance from the points at which the matter vras inserted ; the " three 
incisions" made there healing up without effect. An instructive example 



62 



Dickson, Smallpox. 



[July 



is given in the same place, of the similarity of various eruptions, enough, 
surely, to account for much "confusion" and many mistakes. 

A child eighteen months old, vaccinated a fortnight before, had well charac- 
terized vaccine vesicles on the external labia, and also on the perineum and 
about the anus. The vesicles bore some resemblance to certain forms of vene- 
real eruption appearing about those parts in children and the case was carefully 
examined in reference to this point. 

All such irregularities deserve special study. So also does the retarda- 
tion of the vaccine influence within the system, where it sometimes remains, 
holding by a tenure very obscure. Not to dwell on mere delay of the local 
and general effect of the insertion of the virus, which is stated in various 
instances to have lasted from 1 4 days to six months ; we may refer to an 
example of very peculiar character, related in detail by Dr. Ruprecht, of 
its renewal or relapse after several years' interval. 

A girl of 14, being seized with influenza, complained of pain in each arm at 
the spots where, when an infant, she had been vaccinated ; and in these locali- 
ties vaccine vesicles became perfectly developed. An elder sister was revac- 
cinated with the lymph hence obtaioed; beautiful vesicles formed, and ran a 
normal course. — Yide Brit, and For. Review, April, 1850. 

3. When smallpox shows itself without obvious infection derived from 
a specific instance previously developed, the apparent exception must come 
under one of the heads already discussed. It does not seem to me to affect 
the question, if we admit the fullest efficiency that has ever been supposed to 
belong to what is called "Epidemic influence," unless this influence can be 
shown to act independently of the presence of a case or cases previously devel- 
oped. Nothing can be more vague than the familiar use of the above phrase. 
Every one is aware that all diseases prevail with greater promptness, their 
causes known and unknown act with greater efficiency, over wider spaces, 
and include larger numbers, at certain periods than at others. It is pro- 
bable, indeed, that any malady may find in atmospheric contingencies 
favouring elements ; but these are favouring, fostering, not generative. 
We must not confound the parent with the nurse. Diseases both conta- 
gious and non-contagious thus become epidemic. It is noticeable, too, that 
epidemics vary, at different times, in their degree of malignity or propor- 
tional mortality, which is not, by any means, in uniform correspondence 
with their extent or sway over numbers. Prof. Wood has pronounced it 
"highly probable that the epidemic influence maybe alone sufficient to 
produce smallpox, scarlatina, and other contagious eruptive affections, 
without the co-operation of the specific contagion." Even if the idea be 
correct, the expression here used is too strong. It can hardly be said that 
anything is highly probable, unless some good reason can be given for the 
belief that it has once occurred. I have admitted the possibility of such 
an event ; but it would be an incident both rare and mysterious. No one 
would say that he expected or anticipated it under any contingencies which 
he could describe or define. Epidemic influences, ex vi termini, act upon a 



1862.] 



Dickson, Smallpox. 



63 



great many simultaneously. Influenza, cholera, &c., are known to affect 
numerous subjects at once. On the contrary, the obscurely induced attacks 
of smallpox have always at first, and generally altogether, been confined 
to a single individual, with whom the affair may end ; or it may subse- 
quently spread more or less widely. We have agreed to stigmatize "the 
absence of an efficient system of protection as a national disgrace, almost 
a national crime." The appropriateness of this sentiment, it ought to be 
added, must entirely depend upon the feasibility of such protection. If the 
origin and spread of smallpox be probably ascribed to any unintelligible 
and uncontrollable mode of causation, and such are all epidemic influences, 
then there is neither disgrace nor crime in the failure to protect. Believ- 
ing, however, as I do, that the introduction and propagation of this pesti- 
lence are well enough understood for all practical purposes, I do regard all 
governments as responsible for the institution of proper and relevant efforts 
at prevention and circumscription, and deeply guilty when this is neglected. 

Smallpox propagates itself, or is propagated, 1. By actual inoculation, 
insertion of the virus. 2. By contact with the sick. 3. By near approach 
or immersion in polluted air. 4. By fomites, either applied directly to the 
surface, or acting through the air about them. 5. By diffusion of infec- 
tious matter through the atmosphere to an undefined extent ; which con- 
stitutes, doubtless, the chief, if not the exclusive, element, in epidemic 
dissemination. This is obviously more effective in certain atmospheric 
conditions, known and unknown, often or generally observed to be associated 
with ochlesis, the crowd-poison, which also gives force to the third mode, 
or, indeed, ail of them. Many unfavourable hygienic conditions act 
rather on the constitutions of the subjects, than by multiplying or concen- 
trating or intensifying the subtle virus engendered by the pestilence. 

Inoculation of smallpox is prohibited by law in Great Britain, and has 
fallen into disuse in our own country. Contact with the sick is more diffi- 
cult to be prevented than one would think. It is not known how soon the 
subject becomes a dangerous centre of evil, nor for how long. Near ap- 
proach by accident must often happen, while those ill of mild attacks, or 
convalescent, are permitted to make use of public vehicles and common 
paths. Civilization renders impossible the abandonment of the miser- 
able sick, under any circumstances ; but it is always easy to find nurses 
hardened against infection by previous attacks. Fomites are sources of 
widest danger, because they are of such vast variety, and often, therefore, 
unsuspected. We may refer to all garments, bedclothing, textile furniture, 
such as carpets, curtains, stuffed and covered chairs, &c. The tenacity with 
which such objects retain their evil potency is remarkable. A story is told 
by Mills of a child dying of smallpox in its cradle. The bedclothes were 
carefully washed and put away ; a year after they were brought out for the 
use of another infant, born to occupy the same cradle ; this new-comer soon 
took smallpox, and also died, no other instance of the disease being known 



64 



Dickson, Smallpox. 



[July 



to exist anywhere else in that region of country. Carriages, both public 
and private which have been used for conveying the sick, are dangerous 
fomites. Bank-notes handled by them are very reasonably denounced also 
by Dr. Buckler, of Baltimore. The dead body itself may act very effi- 
ciently as fomites. I remember a case which appears strongly in point. 
During the winter of 1848-49, a young man, a member of the medical 
class of the New York University, died suddenly and unexpectedly in the 
night, under the care of a physician who had not thought him seriously 
ill. I was invited to the autopsy, and observed, when the corpse was un- 
covered, a few dark-red spots on the surface, which were supposed to be 
petechial ; the principal symptoms of his attack having been gastric, with 
great debility, as we were informed. The coffin was taken home to a New 
England village, for burial ; where, at the funeral, some of the relatives 
approached and opened it, to see the face of the deceased, before it was 
inhumed. Of this number, eight were attacked with smallpox,, no other 
persons in the neighbourhood being assailed. It was afterwards thought 
probable that the youth had attended the wards of some hospital in the 
metropolis, and had been affected with the disease which at that time was 
in existence there. 

I have omitted to speak under this category of books, paper, letters, 
solid wooden articles, and the walls and floors of houses, as disputable ; 
although there are instances, repeated often enough on the records, to ex- 
cite caution at least, of the reception of the contagion through the post ; 
by handling walking sticks and other implements ; and by inhabiting apart- 
ments in which the sick had lain long ago, and from which all suspicious 
furniture had been removed. Atmospheric diffusion is, however, by far the 
most injurious method in which this, like other forms of pestilence, propa- 
gates itself. Nothing in nature can be more obscure or hard to apprehend 
than the varying conditions which surround us, all of them comprised 
under the familiar phrase "constitution of the air," though we know not 
whether they are telluric or astral, electric, or thermal; unappreciable diver- 
sities, at one time indifferent to the presence of a contagious malady, at 
another opposed or unfriendly, or unadapted to its spread ; again, giving 
it wings, as it were, and aiding its extension ; exhibiting an evil influence 
by rapid increase of the number of subjects attacked on certain occasions ; 
and on others, by impressing a peculiar character of violence and malig- 
nity upon a narrower range of prevalence. Against this danger, so stealthy, 
so impalpable, no ordinary precautions are of any avail, whether personal 
or hygienic. Of the first forty cases which I saw in New York during 
the epidemic of 1848-49, there was not one who was conscious of having 
approached a patient affected with the disease, or who, upon close inquiry, 
such as it was my habit to make, could be brought to recollect having 
placed him or herself in circumstances of any imaginable suspicion of 
risk. 



#- 



1862.] 



Dickson, Smallpox 



65 



Happily, we are provided with special and relevant means of defence, 
applicable alike in all the varying conditions above enumerated and alluded 
to, and available against all the several modes of extension or propagation. 
Among the strongest points of contrast in the histories of disease, none is 
more striking than this : that certain individuals on the long catalogue 
create in the constitution which they intrude upon, a propensity, or, to 
speak technically, a predisposition to be more readily' affected by them a 
second and a third time, and so on indefinitely ; thus it is with malarial 
fevers, erysipelas, gout, rheumatism, &c. ; while certain others exhibit a 
directly opposite tendency, being, as I have styled them, self-protective ; 
and giving to any constitution over which they have once prevailed, a 
strange immunity against their recurrence. This is the rule — broken 
doubtless by exceptions — but it is the undenied rule. "Upon this peculiar 
characteristic belonging to the exanthemata, is based the hope as to all 
the three, the certainty as to the one under discussion, of being able to 
circumscribe, restrain it, reduce it to subjection, and, if we desire, to extir- 
pate it entirely. 

The most ingenious speculators have offered us no plausible explanation 
of this curious and fortunate fact or law. Of the various conjectures 
thrown out, it may suffice to mention two wild and inconclusive hypotheses, 
which have been suggested by the analogies of vegetable life and growth : 
one, that every human being is born with certain elements of organic 
composition, which afford opportunity or pabulum for certain morbid 
changes. The pabulum of each morbid affection being once consumed, is 
not again reproduced, and the changes in which that consisted cannot again 
take place ; and thus, hooping-cough and measles, scarlet fever and small- 
pox, and perhaps some others defend against themselves. The other hypo- 
thesis is equally fanciful, and assumes that, in the course of certain mala- 
dies, new products are evolved, which are permanently retained in the sys- 
tem, preventive of the same actions which originated them ; as the roots 
of a vegetable are supposed by some to leave in the soil where it has grown 
certain effete matters or exuviae, unfriendly to its life, whence the necessity 
for a rotation of crops ; or as animals even in health, fill any confined 
space around them with noxious efifiuvia, demanding perpetual change of 
air and involvements. The well-ascertained law or fact suffices for our 
cherished purpose. 

Again, it has been long known also that smallpox, which, taken "in the 
natural way," either by contact, near approach, from fomites, or when 
epidemically diffused, is one of the most fatal as well as repulsive of 
human disorders, puts on a far milder and less malignant character when 
introduced into the system by a wound in the skin, "inoculation." Asia 
and Africa, the most ancient seats of this terrible pest, have long known 
and still avail themselves of this mode of palliation. England resisted it 
obstinately, yielded to it reluctantly, and has now fatuitously prohibited it. 
No. LXXXYIL— July 1862. 5 



66 



Dickson, Smallpox. 



[July 



We have been indifferent to it, and act as if averse on principle to any 
interference with every man's right to be poisoned at his own will. Inocu- 
lation was first practised by civilized hands at Constantinople, in 1700; it 
was introduced to the English and brought across the Atlantic twenty-one 
years after ; and so completely superseded by Jenner's vaccination, promul- 
gated in 1798, that in 1840 it was "declared illegal by the British Parlia- 
ment, and offenders sent to prison," says Gregory, "with a good chance of 
the treadmill." Its alleged influence in lessening the mortality of smallpox 
is indeed marvellous, and scarcely credible. The author just named tells us 
that "with ordinary precautions, not more than one case in five hundred 
will terminate unfavourably." He denies positively, and opposes strongly, 
both by fact and argument, the assumption which has prevailed widely, and 
is maintained by Sir Gilbert Blane, that "it disseminated the virus, increas- 
ing the foci of contagion ; and thus favoured the spread of the disease," 
demonstrating, I think, its falsity. Indeed, so much are the violence, the 
suffering, and the proportional mortality of smallpox diminished by inocu- 
lation, that I would advocate unhesitatingly the propriety of universal 
inoculation at as early a period of life as was ascertained by repeated and 
careful experiment to be safe and allowable. I would have such inoculation 
repeated at short intervals, until in every subject the point of absolute inca- 
pacity to receive the infection was fairly reached. This would happen in a 
majority of instances with the first eflScient incision of the virus ; it would 
probably take place in the rarest exceptional cases of renewed susceptibility, 
after a very few repetitions. Those who had gone through this process 
would be proof for the future against the pestilence, and as to them it would 
be annihilated, virtually exterminated. And as all constitutional peculiari- 
ties are hereditarily transmitted, whether of original organization or in any 
way acquired, so this anti-proclivity or acquired immunity would go down 
increasing in force with every generation, until the whole race would be- 
come insusceptible of this horrid mode of dying. But this is only half my 
plan. 

However palliated by inoculation, smallpox would still demand and 
engulf a certain proportion of victims ; and besides, would inflict in its 
course a considerable amount of unavoidable suffering. With grateful 
exultation we may reflect that we have in our hands a means of still 
reducing, to a minimum yet more remarkable, the evil against which we 
are contending. For this purpose we confidently resort to the vaccine. 
Whether of identical origin with variola or not ; whether primarily a 
human disease altered in course and history, clipped and abridged of its 
first atrocious properties by transmission through some of the lower organ- 
isms ; or primarily an equine or bovine distemper, genially adapted to the 
service of our dominant race, vaccine exhibits a close and most beneficial 
relation with smallpox. An enviable immortality glorifies the name of 
Jenner, as having made known this invaluable relation. Although not 



1862.] 



Dickson, Smallpox. 



67 



self-protective, it protects in a remarkable degree against smallpox. This 
protection we have learned is far from being absolute, though Jeniier 
thought and pronounced it so. In his petition to Parliament (1802) it is 
stated that he "had discovered a means of rendering through life the person 
protected by it, 2Derfectly secure from the infection of smallpox." For 
some time the public indulged the same sanguine anticipation, which, I 
need not say, is now universally abandoned. I have myself attended a 
pretty severe case of variola — or as some would insist on terming it, vario- 
loid, in a lady vaccinated by Dr. Jenner with his own hands. In Davy's 
tabular view of the Maltese epidemic, out of 8067 reported cases, 2720 are 
set down as "supposed vaccinated," and 390 as "well vaccinated." But I 
will not dwell on this point. As a protective, vaccine employed alone has 
failed. Perhaps the same failure may be as truly affirmed of inoculation 
employed alone. In Davy's tables, 97 are set down as "having had small- 
pox before." He mentions as authentic the case of "a lady, mother of ten 
children, who had smallpox eleven times ! first in infancy, and afterwards 
when each of her children had it; these last being as severe as the first." 
The books abound with similar statements. It is certain that particular 
constitutions admit one or the other of these analogous affections, and yet 
not both. A case is mentioned in the British and Foreign Review, 
October, 1859, where vaccination was attempted many times in vain ; the 
patient had smallpox severely at the ages of twelve, forty-three, and forty- 
five. What would have been the effect in such an instance of early inocu- 
lation, repeated, as I have proposed, at short intervals, to exhaust the 
proclivity or susceptibility? There is a difference in this respect in races 
as well as individuals. The Easterns are very susceptible of smallpox ; but 
I have heard one of the American missionaries to Siam assert that for 
seventeen years they were foiled in every attempt to introduce vaccine 
among the willing people. Some systems repel both contagions. I vac- 
cinated many times and inoculated repeatedly with variolous virus, all in 
vain, a young lady. She afterwards nursed with impunity a sister ''sup- 
posed vaccinated," who died of confluent smallpox ; this latter had never 
been my patient. 

Now, if the reader has given me his patient attention, he will, I am dis- 
posed to think, agree with me that each of these two inestimable methods 
of protection is unfortunately imperfect, insufficient when employed alone, 
and undeserving of our full confidence. Regarding them as complements, 
each of the other, I would institute the employment of them both. Vac- 
cine is the most certain in its action as a modifier. In all the tables we 
find the proportion of deaths in smallpox after vaccine set down as smaller 
than among those who are marked as "having had smallpox." Yariola is, 
on the other hand, the more efficient preventive or protective. By the 
resort to both of them, we obtain the double advantage of uniform pallia- 
tion, and more certain protection, or obliteration of original susceptibility. 



68 



Dickson, Smallpox. 



[July 



Gregory tells us that smallpox in the unvaccinated is five times more 
fatal than it is to those who have previously undergone vaccination." The 
latter should, therefore, precede the former. Revaccination, at distant 
intervals, better regular, of course, than irregular or capricious, can have 
no advantage over the plan proposed. It is uncertain whether it ever does 
away the susceptibility to its own reception. Many series of experiments 
are required to decide this point, and I know of none but those made by 
Dr. Darrach, of this city, which have not been repeated. I think we have 
reason to doubt whether in all individuals any number of revaccination s 
w^ould be securely protective ; wisdom inculcates the course of greatest 
safety, which consists in following up vaccination by inoculation, especially 
if we repeat the latter to exhaustion of susceptibility. The experienced 
practitioner last quoted, and so often referred to as high authority, goes on 
saying, "I inoculated three of my own children, at the ages of twelve, thir- 
teen, and fourteen, after successful vaccination in infancy, and the result 
was as follows : in two, local affection, without any fever or eruption. In 
the third case, there was local affection without fever, but with papular 
eruption on the seventh day, not advancing to vesicles. I firmly believe 
that these children are now and will remain through life unsusceptible of 
smallpox." In this belief I fully accord with the writer, and entertain 
strongly the opinion that there is no other way of obtaining such complete 
security. 

Let me refer again to the "report" of Dr. Jewell. "In a former report," 
says Dr. J., "I have alluded to the inadequacy of voluntary provision to 
secure us from the ravages of smallpox, and I have elsewhere asserted that 
nothing less than a compulsory law, with a penalty attached for its viola- 
tion, would prove an effectual barrier, &c." What then shall be done? 

There are two difficulties in the way of efi&cient action here. The first is 
the universal vis inertise, opposed not only to all innovation, but to all 
movement of any kind. Yet if the medical profession were as a body to 
engage with earnestness and zeal in their duty, the great inert public might 
be roused, and much good be effected. But at best this would be only a 
partial success. I am satisfied that the inattention, indifference, and inac- 
tion of even the most enlightened communities as to this matter, are owing 
to their want of clear conviction, their imperfect trust in the security attain- 
able by the measures urged ; and this is the second and greatest difficulty 
before us. Nor can such incredulity be considered unreasonable, when we 
reflect upon the vacillation, the avowed scepticism and open opposition of 
experts, and men of weight, influence, and knowledge, both in and out of 
the profession. Recollect that opportunity has never been given for the 
attainment of confidence, Chatham's "plant of slow growth," in any of the 
means brought to their view. Inoculation was from the first unpopular 
and scouted by those who feared to try a new method, involving a reluctant 
familiarity with a dreaded enemy. When it had just outlived opposition, 



1862.] 



Dickson, Smallpox. 



69 



it was supplanted by vaccination, which promised so much, and was at the 
beginning so fortunate. But soon, very soon, this good fortune came to 
an end, and the exaggerated promises were found to be unfulfilled ; and 
disappointed faith shrunk into doubt and disbelief. I do not despair of 
reviving the spirit of earnest inquiry and active experiment. The evil is so 
great in the present, and so menacing for the future, that if physicians will 
everywhere unite upon some system, we may reasonably hope to obtain from 
the constituted authorities the inauguration of some effective measures of 
coercion. A sense of the necessity of harmony among ourselves should 
lead to rational compromise and unity of effort. There are among us some 
who place little reliance upon the protective power of vaccine ; there are 
some who dread the presence, in any form, of variola. None of us, so far 
as I am acquainted with my brethren and their opinions, none of us doubt 
the self-protective immunities of smallpox, or the happily palliative, modi- 
fying tendency of vaccine. Let us then with energy, perseverance, and 
unanimity recommend to all civilized governments the combined employ- 
ment of these two safeguards. Let us procure that it shall be ordained 
that every child shall undergo vaccination by some expert within a month 
after birth ; that as soon as the constitution shall have gone through its 
influence, inoculation with variolous virus shall be performed, and that this 
latter operation shall be repeated again and again at brief intervals, until 
all reasonable satisfaction has been attained, of the entire extinction of the 
susceptibility to smallpox. 

I am aware that there are some, even among my friends, who will regard 
all that I have written as mere Utopian speculation. Others will foresee 
invincible obstacles in the details necessary to carry out any plan which 
may be instituted. To the former I offer my entreaties that they would 
lay aside their inactive scepticism and join in the labours of more hopeful 
or sanguine philanthropists. I might say to the latter that I have not 
found it difficult to prepare a series of ordinances, which I refrain from 
presenting to them, partly because it would occupy too much time and 
space ; but for the still better reason that when it is once determined to 
act in the premises, the first step of such action ought to be a careful and 
deliberate consultation as to the modus operandi. I shall consider myself 
one of the most fortunate and happiest of men, if I prevail in arousing my 
medical brethren and my fellow citizens to some determined and general 
effort at the restriction, palliation, and extermination of one of the most 
enormous evils which afflict our common humanity. 



TO Lente, Amaurosis and other Disorders of the Eye. [July 



Art. IY. — Amaurosis and other Disorders of the Eye, resulting from 
Injury of the Terminal Branches of the Fifth Pair of Nerves. By 
Frederic D. Lente, M. D., of Cold Spring, New York. 

That lesion of the fifth pair at some point within the skull, or of that 
portion of the cerebral substance from which they take their origin, will 
cause a disturbance, more or less serious, of the organ of vision itself, 
sometimes in its function, sometimes also in its structure, terminating occa- 
sionally in its total disorganization, is a fact established as well by the 
experiments of Magendie and other physiologists, as by the observations 
of various pathologists in diseases of the brain. 

A number of cases of traumatic amaurosis arising apparently from injury 
of the external parts adjacent to the eye, which have fallen under my 
observation from time to time, have induced the conviction that disturbance 
of vision, resulting in asthenopia, or in amaurosis, may ensue as well from 
injury of the terminal branches of the fifth pair, as from that portion which 
forms a part of the encephalon. 

The consequences which follow injuries about the orbit, as affecting the 
eye, are referable to three heads : First, concussion, or other injury of the 
brain or eyeball; secondly, development of inflammation, or other disease 
within the eye, resulting in gradual impairment, or loss of vision, sometimes 
even in destruction of the eye; thirdly, a sympathetic or reflex influence on 
the retina or optic nerve, developed sometimes immediately, sometimes after 
a longer or shorter interval, as a result of the direct lesion of the nerve 
filaments, or in consequence of processes of repair succeeding the injury. 
Diseases also of the periorbital region have been followed by phenomena 
that have been referred to the last two heads. 

Modern writers on diseases of the eye devote but little attention to this 
subject, and generally refer the disturbance of sight and other sequelae to 
the first head — that is, direct injury of the eyeball or brain ; in some 
instances also, to the second head. Thus, Lawrence, Middlemore, Sichel, 
Tyrrell, Wharton Jones, Haynes Walton, Mackenzie, all seem to be more 
or less inclined to this opinion. The latter, who enters into the discussion 
of this subject, especially in his later editions, more extensively than the 
others, after relating many instances, as we shall presently see, very plainly 
indicating the nervous injury as the direct cause of the affection of the eye, 
yet concludes his remarks by saying that "the consideration of these facts 
naturally leads us to regard with still greater doubt the alleged occurrence 
of purely sympathetic amaurosis from slight injuries of the fifth pair, and 
to suspect that, in the supposed cases of this sort, there has been, in addi- 
tion to the external injury, either concussion of the eyeball, or disease 
excited within the cranium." The first case which we shall relate, and 



1862.] Lente, Amaurosis and other Disorders of the Eye. 71 

which occurred nearly twelve years ago, during my residence as house sur- 
geon in the Xew York Hospital, led me to adopt a different opinion; and 
a further investigation of the matter only confirmed this opinion. My 
attention has lately been recalled to this subject by the publication, in the 
American Medical Times for March 15, by my friend Dr. Noyes, of the 
New York Eye Infirmary, of a similar case, to the extremely interesting 
history of which I shall hereafter advert ; also by some interesting com- 
mentaries on this case in a succeeding number of the same journal, by M. 
Echeverria. The matter has been invested with a medico-legal interest in 
consequence of the publication of the report of a trial in the last edition 
of Walton's Treatise on the Eye. Dr. Walton and several other surgeons 
of note were employed by the London and Northwestern R. R. Co., who 
were sued for heavy damages by a watchmaker, who had received a very 
trivial injury about the eye, but who subsequently became in a measure 
incapacitated for his particular occupation in consequence, as was alleged, 
of this injury. ** The question of amaurosis, depending immediately or 
ultimately upon injury of the nerve, was raised by the patient's counsel." 
I am now quoting from Dr. Noyes' article: "Mr. Walton testified that in 
his opinion ^mere injury of the nerve-branch on the head can have no 
effect on the function of the retina; that loss of sight, when associated 
luith such lesion, is due to coincident lesion of the eyeball.^ The plain- 
tiff's counsel referred to numerous cases recorded by authorities, disproving 
this opinion, and the chief justice seemed to be particularly severe on these 
records. The medico-legal bearing which, as we see, this question may 
assume, would, of itself, render a full investigation important; for, the 
cases recorded in this paper, taken in connection with the evidence scattered 
among the various authors on diseases of the eye, which we shall presently 
endeavour briefly to collate, will, in our opinion, go far towards invalidating, 
if indeed it does not completely annul this decision of Mr. Walton. But, 
we shall also find that the discussion will have a practical bearing on the 
treatment of certain affections of the eye. We indulge the hope, therefore, 
that though this paper may prove tedious in some of its details, it may not 
be entirely unprofitable. 

-Case I. Antoinette H., 11 years of age, an interesting and intelligent 
girl, was brought to me at the hospital as an out patient on the 6th of 
July,. 1850. On the 4th a boy snapped a percussion pistol near her; and, 
a fragment of the copper cap flying off, struck her in the face. There was 
a small wound on the left side of the forehead near the median line, which 
bled freely for a time, but caused little pain. But little concern for the 
injury was felt at the time; but, on the day following, the little girl com- 
plained of severe pain in the right eye, and around the right orbit, of a 
"numbness^^ extending from the ivound on the left side of the forehead as 
far as the right temple, and also of dimness of vision of the right eye. All 

1 The words are Dr. Walton's ; tlie Italics are mine. 



72 Lente, Amaurosis and other Disorders of the Eye, [July 

these symptoms have been increasing to the present time, especially the 
last. The right eye is now amaurotic, patient having but little more than 
the perception of light; being unable to distinguish with it even large 
objects near her; patient seems rather disinclined to face the full light of 
day. • The pain in and around the eye is quite severe, and is much increased 
hy pressing upon the seat of the wound of the forehead. At this point, 
vy^hich is a little to the left of the median line and about half an inch below 
the line of the hair, there is the appearance of a slight abrasion of the 
cuticle, and a small circumscribed induration, as if from effusion of lymph ; 
no foreign body can be felt. There is a slight redness of the right eye. 
Patient is of nervous temperament, and in rather feeble health; was in 
Paris during the late revolution there, and her nervous system received a 
shock from which it has not yet recovered. Judging that a piece of the 
copper cap had lodged in the forehead, and had originated and was main- 
taining the amaurotic symptoms, I determined, with the concurrence of my 
colleague, Dr. W. H. Church, now one of the surgeons of Bellevue Hos- 
pital, and medical director in the Army, to search for and remove it. After 
making an incision, and searching for some time, we found, imbedded firmly 
in the pericranium, a jagged fragment of cap, w^hich we removed. During 
the somewhat protracted exploration of the wound, patient complained of 
very severe pain extending from it, towards the right eye, and in the right 
eyeball itself. Immediately after the removal of the fragment the pain 
abated, was less than before the operation, and vision was in a great mea- 
sure restored, patient distinguishing even small objects without difficulty. 
Both Dr. Church and myself were much surprised and gratified at the un- 
expected success of our little operation. Directed quietude, low diet, a 
gentle laxative, and the application of a cooling lotion to the eye. 

July t. The "numbness" complained of as affecting the right side of the 
forehead, has there abated, and has extended to the left temple. The left 
eye also is painful, slightly injected, and vision somewhat impaired. The 
inflammatory symptoms of the right eye have much increased; the pain in 
the globe is deep seated, and increased by pressure; vision of this eye still 
better than it was before the operation, but not so good as it was just after 
it. Skin and pulse natural; bowels open. Directed leeches to temples, 
and mercurial and anodyne ointment around orbits ; rest in bed in a mode- 
rately darkened room. 

8^/?.. Slept little last night. Complained of increased pain in right eye, 
and around the orbit; complains also of "soreness" over the whole scalp. 
There is now only very slight anaesthesia on right side of forehead, and 
that on the left side has not increased. Directed emplast. lyttae post dext. 
aur. Anodyne at bedtime. 

9)th. In the early part of the evening the pain became much aggravated, 
extending over the forehead, scalp, and right side of the face; the right 
cheek also, over the lower jaw, became swollen, and tender to the touch. 
The pain was repeatedly relieved by the tinct. aconite. Anodynes rejected 
by the stomach. During the night, complained of coldness and numbness 
of the extremities; this was relieved, after a time, by sinapisms, and she 
slept during the latter part of the night. This morning, feels tolerably 
comfortable. Pulse and skin still natural. Has now no uneasy sensations 
in the left eye, and vision with this eye nearly perfect. The anaesthesia on 
this side has also nearly disappeared. The pain in right eye and around 
orbit increased; vision about the same. The tumefaction about the lower 
jaw still exists to some extent. Continue treatment. 



1862.] Lente, Amaurosis and other Disorders of the Eye. 73 

llfh. Was called to patient last evening, and found her apparently suf- 
fering greatly with neuralgic pains in the face, neck, and chest; the slightest 
pressure on the integument aggravating the pain. The pain in the back 
of the neck is described as being the most severe; and there is inability to 
flex the head; jaws swollen slightly, and spasmodically closed; skin hot, 
pulse frequent; some difficulty in micturition; had vomited several times ; 
complained also of her hands being asleep. Ordered sinapisms to feet ; 
tinct. opii camph. with valerian pro re nata. This morning is quite com- 
fortable. Fell asleep after one dose of the medicine, and rested quietly. 
Pain in the eye much abated ; no pain elsewhere : skin pleasant, pulse 
natural. 

12th. Improving; no exacerbation of pain last night. Can read tole- 
rably fine print with the right eye. 

13th. Last evening was again attacked with the neuralgic symptoms ; 
temperature of skin not much increased; pulse slightly accelerated. Ap- 
plied the aconite, and gave one dose of the antispasmodic mixture, when 
she fell asleep. Tongue much furred ; is quite feeble ; has a voracious 
appetite, but is not indulged. Chicken soup, with farinaceous food, R. 
Hydr. submur. gr. v hor. s. ; ol. ric. mane; quiniee sulph. gr. i ter die. 

14^7?. Better; "quite welF' s/?e says. Has been moving about the house, 
against orders. No pain in eye. Directed some meat, and quin. sulph. 
gr. V, at 2 o'c. to ward off another paroxysm. Hor. som. hydr. c. creta 
gr. V ; ol. ric. mane. 

16th. Had a slight exacerbation last night ; complained of pain in the 
right eye, but it extended no further. Eye looks perfectly natural, with 
the exception of slight injection of the sclerotica, which is fast disappear- 
ing. Some asthenopia, and increased lachrymation. 

11th. Last night had another violent attack of pain in the eye, but no 
other neuralgic symptom. The quinia was omitted by mistake yesterday 
afternoon. The eye looks much worse, and vision is much impaired. R. 
Leech to Schneiderian membrane. 

19//?,. Doing well ; repeat leech. 

21st. Eye now appears to be normal, but is weak. Continue quinia and 
wear a shade over the eyes. 

30//?. Health improving ; vision perfect ; pupil acts well. 

December 14. My little patient called on me to-day. Seems quite well ; 
the eyes have a perfect appearance, but she has, with the right, visus dimi- 
diatus. Lost all traces of her after this date ; heard that she had removed 
to Philadelphia. 

Taken in connection with the above, the following cases, reported in 
1842-43 in the London Medical Gazette, by the late Dr. W. C. Wallace, 
a skilful and well-known oculist of New York city, which I take the liberty 
of transcribing entire, are extremely interesting : — 

Case II. Patrick Burns, 35, stonecutter, on the 8th Oct. was attacked by seve- 
ral men, knocked down, and wounded over the right foramen infra-orhitarium. 
The wound gave so little trouble that in two days he went to work. Ten days 
after, the vision of this eye became indistinct; and, imagining that the dimness 
was occasioned by the scab, he picked it off, though without the least improve- 
ment. He was soon obliged to abandon .work altogether. The sight of the 
affected eye became so obscure that he could not make out an object; though, 
when the hand was passed across the eye, he could tell that there had been 
something before it. On the 13th November, when I first saw the patient, I 
dissected out the cicatrix, which was unusually prominent ; and, on cutting it 



Y4 Lente, Amaurosis and other Disorders of the Eye. [July 

open, I observed in the centre a small piece of steel. R. Strych. gr. vj : alco- 
holis ^ij ; acid. acet. gss. M. Fricentur tempera m. et n. Pil. cal. et colocynth. 
17th, wound nearly healed, and vision much improved. He can now see the 
fingers held before the eye. He can, but with much difficulty, distinguish large 
letters, and expresses himself as relieved of uneasy sensations about the side of 
the head. 

Case IH. John Williams, 25, butcher. On the 8th of November, during an 
election riot, received, from an unknown weapon, a wound on the right lower 
eyelid, helow the edge of the orbit, and midway between the foramen infra-orhit- 
arium and tendon of orbicularis palpebraru7n. According to his own account, 
both eyes immediately became blind, and he had to be led home. As, on the 
second or third day, the vision of the right eye was perfectly restored, he thinks 
that the temporary deprivation of sight was caused by the tumefaction of the 
lids. Since the injury, the left eye has been completely amaurotic. With this 
eye he cannot recognize the least ray of light, and is even insensible to the glare 
of a magic lantern. The iris is somewhat expanded, and totally immovable 
when the other eye is closed, but when both are open, their motions perfectly 
correspond. With the exception of the cicatrix under the right eye, and the 
total loss of vision in the left, there is no appearance of disease. With great 
difficulty I persuaded the patient to allow me to remove the cicatrix, which was 
found to contain a smcdl foreign body. But, by no entreaty could I persuade 
him to allow me to bring the edges of the wound together by stitches. Although 
he promised to return, he never afterwards made his appearance, and I have not 
been able to find any traces of him. 

Happening to mention these cases to the late Dr. J. Kearney Kodgers, 
then one of the surgeons of the New York Hospital, and one of the founders 
of the New York Eye Infirmary, he related a case in point, which had fallen 
under his own care. The notes of this case I have unfortunately lost, and 
cannot therefore give its very interesting history with accuracy; but, as I 
now remember it, the substance was the following : — 

Case IY. A little girl, five or six years old, the child of a friend of the 
doctor, was playing under a table ; and, on rising up suddenly, struck her 
head against the edge of the table. Some time after this it was noticed that 
vision of one eye was becoming very imperfect, and Dr. Rodgers was con- 
sulted. The blow on the head was not, at that time, considered by the 
parents as having any connection with the disorder of vision, and was 
therefore not mentioned. But the doctor, on running his hand over the 
head of the child, in examining the eye, noticed that she flinched w^hen he 
touched a particular spot of the scalp ; and the mother then said that, in 
combing the hair, the child often cried when the comb came in contact with 
this spot, and then related the history of the accident. On closer exami- 
nation a cicatrix was discovered, and was excised. After the wound had 
healed, vision was either much improved, or rendered perfect, I cannot 
distinctly remember which. But the doctor regarded it as a remarkable 
circumstance.^ 

' These cases, and others wliicli will be alluded to, bear out one of the conclu- 
sions arrived at by Doctor Skokalski in bis investigations concerning the functions 
of the fifth pair, viz., that "sight does not depend solely on the retina, but on a 
combined action of the retina and fifth pair." Comparative anatomy also furnishes 
us with the important fact that, in s'ome animals, whose visual apparatus is -but 
slightly developed, the optic nerve is wanting entirely, and its place supplied by 
a branch of the fifth pair ; as in the mole tribe ; but most unequivocally, in the 
proteus anguinus. 



1862.] Lente, Amaurosis and other Disorders of the Eye. 75 

Remarhs. — Hippocrates remarks, ''The sight is obscured in wounds in- 
flicted on the eyebrow, or a little higher" (Middlemore). Beer makes a 
similar observation, and relates several cases in support of his opinion. He 
says that ''he has had frequent opportunities of accurately observing and 
curing amblyopia and amaurosis, occurring in consequence of wounds of 
the eyebrows." Also, that "where such wounds are judiciously managed, 
and speedily healed by adhesion, no bad consequence ensues ; but when 
suppuration occurs, followed by the granulating process necessary for 
secondary union, the divided nerves are involved in the inflammation, and 
subsequently included in the hard cicatrix, and, as he conceives, compressed 
and irritated.'" Larrey seems to have had the same idea, for he says, "In 
incisions about the orbit, we should avoid, as far as possible, injury of the 
ramifications of the frontal nerve; or, if we injure it, we should be careful 
to make a complete section." And, as Middlemore remarks, "few surgeons 
have had a greater extent of experience in this particular form of injury." 
Middlemore himself records a number of interesting cases of amaurosis from 
orbital wounds ; though he appears to be somewhat sceptical as to whether 
it should in general be attributed to the lesion of the nerve. He says, 
"Amaurosis may arise during the period of dentition ; it may take place 
from the irritation of a carious tooth ; from laceration, or other injury of 
the supra-orbitary nerve." He relates a case in which Mr. Howship 
removed an encysted tumour from the scalp, which produced ^'marked and 
permanent improvement in vision.^'' Another case, in which M. Demours 
removed a tumour from the neighbourhood of the eye, and thus produced 
amaurosis. Another from the Edinburgh Medical and Surgical Journal, 
"which would appear," he says, "to prove that wounds of the infra- 
orbitary nerve may restore the sight of an eye which has long been lost 
from an amaurotic affection." "A man was affected with perfect gutta 
Serena of the right eye, and had the sight of the eye restored, he thinks, in 
consequence of receiving a smart blow in the neighbourhood of the infra- 
orbitary nerve of the right side of the face." Another still more striking 
case, in which a person received "a wound just above the right eyebrow 
from a piece of glass, which was removed immediately after the accident." 
When the wound had healed, "the sight of the right eye was very nearly 
lost; he had a painful sensation in the neighbourhood of the cicatrix, and a 
singular sense of creeping, and pinching and quivering of the upper eyelid 
and the integuments of forehead." "I made a free incision of the cicatrix 
down to the bone, and all uneasiness at once ceased, and the eye, shortly 
after, assumed its healthy character and functions, and vision was perma- 
nently restored.''^ Lawrence, after relating two or three cases of amaurosis 
following wounds and the formation of cicatrices over the brows, remarks, 
"It is still a matter of doubt whether injury of the frontal nerve may cause 



' Lawrence, American edition, 1854, p. 124. 



76 Lente, Amaurosis and other Disorders of the Eye. [J^ily 



amaurosis." Aud yet, he adds, "injmy or other irritation of the trigeminus 
may bring on impaired vision or amaurosis." "The sympathy between the 
trigeminus and the immediate nervous apparatus of vision affords the only 
explanation of some apparently obscure cases, in which amaurosis seems to 
have depended on a carious tooth, or on some other local affection seated 
in the head." (Op. cit.,p. 578.) 

The following remarks by Marshall Hall were reported in the London 
Lancet for 1837-38. "These experiments," alluding to those made by 
Magendie, "are not the only evidence we possess of the influence of the fifth 
pair on vision." "In an interesting case under my own care, a partial 
amaurosis of the right eye has arisen apparently from the caries of the 
upper canine tooth of the right side." It was augmented by unsuccessful 
efforts at extraction. It has not ceased, however, since extraction was 
effected. "These facts," says he, speaking of this and other cases, "with 
the similar results from wounds or tumours of the supra-orbit-ar branch of 
the fifth, appear to me to confirm the extraordinary experiments of Magen- 
die." Hennen says,"^ "I have met with one or two cases of amaurosis from 
wounds of the supra-orbital nerve." "Scarpa," he says, "doubts of the 
possibility of the cure of amaurosis from this cause, and mentions Valsalva's 
case as the only one on record. Mr. Hey, however, states another in the 
Medical Observations and Inquiries, vol. v. M. Larrey mentions another, 
Yicq d'Azyr, who gives a case of amaurosis from a wound of this nerve, in 
the Histoire de la Societe Royale de Jledecine, Annee 1776," says he has 
" since divided this nerve in quadrupeds, but without producing any such 
effect." 

That defective vision may result as the direct consequence of irritation 
of the terminal branches of the fifth pair may also be inferred from the 
effects of remedial applications to these nerves, and from the phenomena 
observed to follow irritations and injuries of other branches not so imme- 
diately connected with the eye. Some of these instances it will be proper 
to mention. A friend of the writer, a distinguished surgeon of Xew York 
city, was incapacitated for business by violent neuralgia of the face; after 
having suffered some time with it, he noticed that one of his molar teeth 
was defective, and went to a dentist to have it examined ; not supposing, 
however, that it had any connection with his neuralgia, since it gave him 
no pain ; its removal was advised ; the operation was scarcely over before 
the doctor experienced complete relief from his excessive pain. "I felt," 
he said, "as if I could have shouted for joy." A lady, a short time since, 
applied to me to extract a tooth for her little daughter, which, she said, 
had been causing her excruciating pain day and night ; but, on examina- 
tion, I could discover no defect ; and prescribed some anodyne remedy, 
which gave only temporary relief. A dentist was called in, who also de- 



' Principles of Military Surgery, 2d Edin. ed., p. 346. 



1862.] Lente, Amaurosis and other Disorders of the Eye. 77 



clined extracting a sound tooth ; but on a second visit, and a closer exami- 
nation, detected an unsound tooth at some distance from the offending one, 
and extracted it. The pain instantly ceased, and did not recur. Mackenzie 
relates a remarkable case in point. A man had violent neuralgia of the 
eye, soon succeeded by amaurosis, and continuing, notwithstanding various 
treatment, from the autumn of 1825 until the beginning of 1827. At this 
time M. Galenzowski, to whom he applied, ''found vision of the left eye lost 
and the pupil dilated. He extracted a decayed tooth from the left upper 
jaw, and, to his astonishment, and that of the patient, found, attached to 
its root, a splinter of wood, supposed to have been originally attached to a 
toothpick of wood. Nine days after, tlie patient had entirely regained his 
sigM.^^^ Mackenzie relates another equally remarkable case, occurring in 
the practice of Doctor Yan Zandt, of St. Louis, ''of a young man affected 
with complete amaurosis, excited by the persistence of two deciduous teeth. 
As S0071 as they were extracted the patient looked up as if terrified, Siud found 
his vision restored.^' "Morgagni, Notta, Deval, Taviguot, and others," 
says M. Echeverria, "have known amaurosis to be caused by neuralgia, and 
to disappear as soon a.s the neuralgia was cured." (The Italics in the 
above references are my own. — L.) Such cases as these might be multi- 
plied, but it is scarcely necessary. ^ 

As regards the illustrative effects of the application of remedies above 
alluded to, I will adduce the following case : — 

Soon after the occurrence of Case I, I was led to try the effect of the 
application of electricity by induction to the orbital branches of the fifth 
pair for defective vision, apparently not depending on internal disease of 
the eye (the ophthalmoscope had not then come into use). An old sailor 
in one of the upper wards of the south building of the N. Y. Hospital, had 
recently become so amaurotic that he was unable to distinguish anything 
but large objects about the room. I applied the poles of the apparatus to 
the supra and infra-orbital branches respectively, and continued the appli- 
cation for near half an hour daily. After two or three days, he noticed 
improvement of vision ; could distinguish a stovepipe hole in the wall, which 
had before been invisible to him. Subsequently he could read the large type on 
the cards hanging on the walls ; and eventually the large type of a book.^ 

Dr. Addinell Hewson, lately of Wills' Hospital, published a year or two 
since a number of cases of complete relief of the most intense photophobia, 
by one or two applications of electricity to the orbit ; he alleges almost 
invariable success. In this connection I will quote the following paragraph 
from a lecture by M. Echeverria, published in the American Medical Times, 
for May, 1861 : "In applying electricity to the eye, you should always be 
aware of the nature of the current to be employed." "An unfortunate 
accident happened to the celebrated Duchenne de Boulogne, who, not know- 

1 Arcliives Generales de Medecine, tome xxviii. p. 261. Paris, 1830. 

2 [For other cases see Lawrence's Treatise on Diseases of tlie Eye, edited by Isaac 
Hays, M.D., Philadelphia, 1854, pp. 61G-618.— Ep.] 

2 Magendie proposed galvanism for the amaurosis succeeding injuries of the orbit. 



t8 Lente, Amaurosis and other Disorders of the Eye. [Jidy 

ing the effect of the continuous current upon the optic nerve, applied it to 
a patient afflicted with paralysis of the facial, and caused the already men- 
tioned mischief (loss of sight)." I have, however, in one case applied the 
continuous current daily, for two or three weeks, to the orbital nerves for 
weakness of vision, with good effect. 

Since writing the above, my attention has been called to a report of 
cases treated at Wills' Hospital, for Diseases of the Eye, in 1839, by the 
editor of this journal,^ from which I quote the following extracts, as bearing 
on the effects of injury of the supra-orbital nerves, and on the effects of the 
galvanic current. It will be observed that Dr. Hays' experience agrees 
with my own with regard to the effect of the continuous galvanic current. 

Case. Imperfect Amaurosis of Bight Eye from a Blow — Bartial Be- 
covery. — Abraham Corbit, 41, admitted Oct. 5, 1839. Nine days ago, 
whilst splitting wood, a piece flew up and struck him on the right eye. He 
experienced little or no pain from the blow at the time, nor did he suffer 
any subsequently. Seven days after the accident he was quite blind in the 
right eye. Appearance of eye perfectly natural. Patient had a variety 
of local and constitutional treatment with varying success. Finally, gal- 
vanism was tried by Dr. Hays with some improvement. Patient then left 
the hospital, but returned afterwards in a worse condition. "The treat- 
ment, to which he was now subjected, consisted in the frequent use of gal- 
vanism, with the addition, after a few days, of strychnia, conveyed into 
the system by the galvanic current," with some other adjuvants. "By 
these means," says Dr. H., "his sight improved." He was subsequently 
discharged relieved. 

The following interesting observations are appended to the case by Dr. 
Hays. 

"Whether the amaurosis in the present instance was the result of concussion 
of the retina, or of injury of the supra-orbitar branch of the fifth pair cannot 
positively be determined, as it was impossible to learn from the patient whether 
the blow was directly on the eye or on the brow, the injury being so slight as 
not to have attracted much attention at the time, and the blow had left no mark. 

" The remedy which was most useful in this case was unquestionably galvanism. 
We have an evidence of this not only in the improvement which followed its 
application, but in the still more striking fact, that the patient actually saw 
better ivliilst subjected to the galvanic action. On the 6th of December, whilst 
the galvanic current was passing from the mastoid process to the superciliary 
ridge, I requested my intelligent friend. Dr. John Neill, to hold before the patient 
some letters, and I asked him if he could distinguish them : he replied, * I see 
better than I could.' The galvanic current was then interrupted by disconnect- 
ing one of the wires from the plates, and which was done without the patient's 
knowing our object. The letters being still held up, the patient in a minute or 
two requested the letters to be held nearer, then farther off, and finally he ob- 
served, 'I do not see as well as I did just now.' The connection being again 
made, the patient almost immediately and with apparent surprise exclaimed, 'I 
see better, again.' The patient was not aware of our object in this experiment, 
and though of course he must have been sensible of a difference in the effect, 

' See number of this Journal for August, 1840. 



1862.] Lente, Amaurosis and other Disorders of the Eye. 79 



still he did not know, as the poles were all the time applied to his head, that he 
was at times freed from the action of the apparatus. 

" In a case of a similar kind, that of J oseph M. Sutter, a carpenter, set. 43, ad- 
mitted October 18, 1836, a complete cure was effected by galvanism. This man 
trod upon a log, which tilted up and struck him over one eye. When admitted 
he had complete amaurosis of that eye. Yarious remedies were employed, 
among others moxas, with little benefit. I then resorted to galvanism, the very 
first application of which was productive of marked improvement, and its em- 
ployment for an hour, two or three times a week, for five weeks, effected a com- 
plete cure. He was discharged January 3, 1837, well. 

"In Sutter's case, and also for Corbit when he was the first time in the house, 
the galvanic apparatus employed was a Cruickshank's battery of twenty pairs 
of plates one and a half inches square. Subsequently for Corbit we used one 
with fifty pairs of plates three inches square. When this was in full activity it 
was too powerful for our purpose, and only half or two-thirds of the plates were 
usually employed. The connection was made by means of leaden wire con- 
ductors, to one end of each of which were soldered a slip of copper, and to the 
other a hemisphere of brass, the flat surface of which was filed into grooves 
crossing at right angles, so as to form a number of sharp points. Over these 
were tied thin disks of sponge, which were kept moist with a solution of com- 
mon salt. When we desired to introduce the strychnia into the system we 
moistened the sponge attached to the negative pole, and sometimes both, with a 
solution of this substance. That the strychnia may readily be conveyed into 
the system by this means is shown by the experiments of M. Fabre-Palaprat 
(see this Journal for February, 1834, p. 561), but also by the fact that usually 
much greater twitchings of the muscles were observed when the solution of this 
substance was employed, than when the sponge was wet merely with the solution 
of common salt. When the whole force of the battery was not wanted, instead 
of placing the slips in the extreme cells, they were placed in cells more or less 
remote, according to the power required ; thus the force was easily regulated. 

" We are persuaded that properly employed, galvanism is a valuable and effec- 
tive remedy for certain forms of amaurosis. 

We tried electro-magnetism, in several cases in the hospital during our service 
in 1839, and also in private practice in a number of cases, but we are not sensi- 
ble of its having been productive of the slightest benefit in a single instance. 
From this it would appear that, for remedial purposes, a regular and constant 
galvanic current is more useful than the violent shocks produced by interrupted 
currents, as induced by the electro-magnetic apparatus. A DanieU's battery 
would probably therefore be the best apparatus." 

As regards the effects of disease of the peri-orbital region, alluded to in 
the preliminary remarks of this paper, it has been noticed that cancerous 
and other ulcerations have been followed by amaurosis, whether dependent 
on reflex disease excited within the eye, or reflex irritatioyi, as in some of 
the cases of cicatrices and tumours referred to, could not have been deter- 
mined without the aid of the ophthalmoscope.^ In some of the cases 

' The good effect of the free application of tinct. iodine to the forehead iu photo- 
phobia is probably not so much due to mere counter-irritation as to a stimulating 
effect on the filaments of the supra-orbital nerves. 



80 Lente, Amaurosis and other Disorders of the Eye. [July 

recorded or referred to in this paper the injury has evidently been too 
trivial, that is, too little violence has been inflicted to produce concussion 
of the eyeball or brain ; we can then only look to inflammation developed 
within the eye, and consequent effusion between its coats, or to reflex irri- 
tation, as the cause of defective vision. We consider that we are justified 
in referring to irritation as the cause, when we have, as in Case I, and in 
Dr. Yan Zandt's case, improvement of vision following immediately upon 
the removal of the foreign body; but the ophthalmoscope has now furnished 
us with more positive evidence. In Dr. Noyes' case, the patient was a 
physician ; a blow on the orbit, apparently not injuring the eye at the 
time, was followed by total blindness, and by partial anassthesia of the parts 
supplied by the supra-orbital nerves. Subsequently the normal sensation 
returned, but the vision did not. A thorough ophthalmoscopic examina- 
tion by Dr. Noyes revealed perfect integrity of every portion of the internal 
structure of the eye. In his concluding remarks. Dr. Noyes says, "The 
loss of sight was the direct result of the blow, it was immediate, it was 
total. No cause appears to explain it save injury to ^the supra-orbital 
nerve ; yet, how to connect these facts understandingly is certainly very 
difficult." It may be, indeed it has been repeatedly objected to the theory 
of reflex irritation accounting for this phenomenon, that we see a great 
variety of wounds and cicatrices in various situations around the orbit, and 
yet seldom see any disturbance of vision in connection with them. "It is 
well known," says Mackenzie, " that every wound of the branches of the fifth 
pair does not produce amaurosis." This is undoubtedly so. Since my 
attention has been specially directed to this subject, I have noticed numbers 
of instances of well-marked cicatrices about the orbit not attended by im- 
pairment of vision. We know equally well that an immense majority of 
punctured and contused wounds of the hands and feet are not followed by 
tetanus ; yet, occasionally a very trivial injury of these parts is followed 
by tetanus and death, and the wound is none the less regarded as the cause 
of the tetanus, because it fails to succeed so many similar injuries. We also 
are aware that hundreds of stumps, after amputation, heal without subse- 
quent trouble ; but that, nevertheless, nerves are sometimes so implicated 
in the cicatrix as to give rise to such intolerable neuralgia of the stump as 
to necessitate reamputation. 

There are several features in the rather remarkable history of Antoinette 
H. which require some notice before concluding this article. It was ob- 
jected by a very distinguished oculist, to whom the case was related soon 
after its occurrence, that the wound, being on the left side, the amaurotic 
symptoms should have affected the left eye, and not the right. But, this 
is not more remarkable than that disease in one tooth should occasion a 
violent toothache in another perfectly sound; or that irritation of the nerves 
of the stomach by acidity should induce violent neuralgia of the supra-orbital 
nerve; or that an irritating application to the mucous surface of the eyelid 



1862.] Lente, Amaurosis and other Disorders of the Eye. 81 

should determine also an immediate irritation of the Schneiderian membrane, 
succeeded by violent sneezing; or that simply touching the memhrana tym- 
2Mni with a probe should sometimes give immediate relief to a toothache. 
We see, moreover, that in other cases, the same phenomenon has been ob- 
served as in one of Dr. Wallace's cases. We notice, also, that pressure 
on the wound caused pain, not in the left but in the right eye, which was 
also aggravated during the steps of the operation, and materially mitigated 
after its completion. Perhaps the most striking feature of the case was 
the immediate though not complete relief of the amaurosis by the abstrac- 
tion of the foreign body. She instantly exclaimed, "Now I can see with 
it," though suffering from the smarting of the wound. This fact, taken 
in connection with the subsequent history of the case, the frequent subsi- 
dence of the symptoms, and their sudden return, w^ithout any obvious cause; 
the violent train of neuralgic symptoms which ensued, the extension of the 
''numbness" to the left side of the face, and the coincident affection of the 
left eye; the rapid and simultaneous subsidence of both symptoms, together 
with the occurrence, months afterwards, of visvs dimidiatus, is worthy of 
particular notice.* I would also call attention to the periodical character 
which the symptoms for a time assumed ; the exacerbations occurring on 
alternate nights, and finally yielding to quinia; likewise to the violence of 
the neuralgic symptoms, simulating at one time tetanus, in the rigidity of 
the muscles of the jaws, the spasms of those of the back of the neck, and 
their aggravation by attempts to flex the head on the chest, thus developing 
a quasi opisthotonos. Such phenomena are not unparalleled in such inju- 
ries. Camerarius relates a case where a slight wound near the outer can- 
thus of the eye was followed by alarming, symptoms, among which was 
temporary hemiplegia. And various writers, as Desse, Morgagni, Petit, 
record cases in which the most severe symptoms, in one or two instances 
resulting in death, followed apparently trifling injury about the orbit. As 
regards the intermittent complications, the following case, which can only 
be alluded to in general terms, is apropos. A very distinguished politician, 
who is just now attracting considerable attention, became affected, a few 
years ago, with violent ophthalmia of one eye; the suffering was severe, 
and the symptoms increased notwithstanding the most assiduous medical 
attention, resulting in ulceration of the cornea, and even threatening the 
life of the patient. At this time, a physician at the south, who had for- 
merly treated the patient, hearing of his critical condition, wrote to his 
medical attendant to try quinine in full doses: this was done, and very soon 
an improvement was manifest; the inflammatory symptoms subsided, and 
the patient recovered, but of course with the loss of vision, and some de- 
formity of one eye. As bearing on this case, I quote the following para- 

' It is worthy of note that an older sister of the patient has total amaurosis of 
one eye, which resulted from a fall on the head. 
No. LXXXYIL— July 1862. 6 



82 



Ash HURST, Burns. 



[July 



graph from Todd and Bowman's Physiological Anatomy : "The study of 
the pathological conditions of this nerve illustrates its physiology in a 
highly interesting manner. Frequently the branches of this nerve, in 
greater or less number on one or both sides, may, according to the humoral 
view, form a focus of attraction for a morbific matter generated in the 
blood, in persons exposed to the paludal poison, or in persons of rheumatic 
or gouty constitution ; in these cases, as in most others of similar pathology, 
the neuralgia occurs in paroxysms of greater or less severity, each paroxysm 
being followed by a period of convalescence, which lasts, it may be sup- 
posed, until the morbid matter has been again accumulated in sufficient 
quantity to induce a high degree of irritation of the nerves." 

In my case no miasmatic development has previously been noticed, nor 
had she been exposed to paludal poison. 

Cold Spring, April 18, 1862. 



Art. y. — On Burns. By John Ashhurst, Jr., M. D., late Senior 
Resident Surgeon to the Pennsylvania Hospital. 

The occurrence in our city, at an interval of only six months, of two 
such terrible accidents as those of the Continental Theatre, in last Septem- 
ber, and of Jackson's cartridge factory, in March, has drawn attention in 
the profession more strongly than for a long time before to the treatment 
of burns, avowedly the w^orst class of cases in surgery. 

As from my official connection on both of those sad occasions with the 
Pennsylvania Hospital, in which institution a large number of the sufferers 
were received, my experience in these accidents has been larger than falls to 
the lot of many surgeons, I have thought it might not be uninteresting to 
make some short remarks upon the nature of such injuries, and the mode 
of treatment which has in the hospital been found most efficient. 

No cases demand more urgently immediate and judicious treatment than 
burns, and yet perhaps in no cases are more ignorance and incompetence 
shown by too large a number of medical men. I shall not attempt system- 
atically to discuss the pathology and symptoms of burns, but shall glance 
rapidly at the indications and modes of treatment. 

And first, the burn is to be looked upon as a constitutional more than a 
local affection. The first question should be, does the sufferer feel cold ; 
and his pulse and respiration should be carefully observed. Put the patient 
instantly to bed and cover him with as many blankets as can be obtained ; 
give him quickly a moderate amount of stimulus and a decided anodyne, 
such as sixty drops of laudanum with an ounce of brandy. The first danger 



1862.] 



AsHHURST, Burns. 



83 



is from shock : of ten patients received into the PennsylYania Hospital last 
September from the fire at the Continental Theatre, six died within twenty- 
four hours and from shock ; some having never reacted, and some after 
partial reaction sinking again with frightful rapidity. And when this 
secondary shock comes on, the patient will, as far as my experience goes, 
certainly die. 

Do not be in a hurry to dress your patients before attending to their 
constitutional treatment ; remember that they will perish from shock if 
reaction be not obtained, and that they will bear the necessary exposure of 
having their wounds dressed much better after reaction, than while in the 
shivering almost collapsed state in which you will probably find them when 
first called. 

Brandy and opium are the remedies most to be relied on in the treatment 
of burns. Brandy should be given in the form of milk-punch in preference 
to being mixed merely with water, as furnishing digestible food at the same 
time with the stimulus, and being less likely to intoxicate than when given 
in the native state. If you should be so unfortunate as to make your 
patient drunk, or as is very apt to be the case if your patient is drunk when 
brought to you, promote reaction as much as possible by external stimula- 
tion and use only the more diffusible stimulants internally, especially the 
preparations of ammonia. Carbonate of ammonia in doses of five grains, 
made into an emulsion with gum and sugar, may be advantageously given 
as often as every half hour, and is probably the best of the ammoniacal 
preparations. In an emergency the aromatic spirit of ammonia* in doses 
of half a teaspoonful, or even the common hartshorn mixed with sweetened 
water may be used. The amount of stimulation which is well borne and 
even necessary in these cases is surprising. For weeks and weeks I have 
given patients two ounces of milk-punch containing one-third brandy, every 
hour day and night, making a pint of brandy in the twenty-four hours, and 
this to delicate women and perfectly sober men. Large doses of opium are 
also required. I generally give as much as half a grain of the sulphate of 
morphia every six hours. Almost every one of the twenty-two cases which 
came into my wards on the twenty-ninth of March, had a tablespoonful of 
the officinal Liq. morpli. sulpliat.,''^ or thirty minims of laudanum, at 
intervals of six hours, for many days ; and this was no more than enough 
to quiet the nervous jactitation and restlessness which is one of the most 
distressing syn»ptoms of burns. 

When the surgeon has seen to the general condition of his burnt patients, 
and not before, he may properly inquire as to the extent of their injuries. 
And upon this must in a great degree his prognosis be formed. 

If half of the surface be involved, no matter how superficial the bum 
may be, or how good may be the patient's condition, he will almost surely 
die. Even a burn of one-third of the surface, if it be over the trunk, will 
almost necessarily prove fatal. And in no case should a recovery be cer- 



84 



AsHHURST, Burns. 



[July 



taiiily predicted, for burns are not only the most mortal, but the most 
deceptive injuries the surgeon is called upon to treat. 

Only a small portion of the surface is to be dressed at once, and it is 
well to have some systematic mode of procedure. I usually dress the arms 
(for they are almost always involved) before any other part, then proceed 
to the body, and dress the face last : this is important, as the dressings 
cannot be applied as closely to the face as to other parts, and are apt to 
fall off and require renewal during the changes of position necessary for 
securing the dressings to the chest or back. 

The material generally used at the hospital as a primary dressing is the 
"carron oil," consisting of linseed oil and lime water. This is the most 
convenient application; its results are I believe as good as can be obtained 
from any other, and in my practice it has been found far more soothing 
than anything else I have made use of. 

The zinc paint is a good dressing, but requires to be frequently renewed, 
as it becomes dry, and is then very irritating. It is made by incorporating 
the oxide of zinc with linseed oil, and is applied by means of a brush. 
Kentish's ointment I have used, but do not see any advantage it possesses 
over the carron oil, while it is not nearly so comforting to the patient, and 
is more difficult to be procured when the emergency suddenly arises. 

I have also painted burns with the solution of lunar caustic, as recom- 
mended by Mr. Skey, but have not observed that the sensibility of the parts 
so treated was diminished by the application. 

I therd*ore decidedly recommend the ''carron oil" as the best dressing 
with which I am acquainted. If linseed oil cannot be obtained, good lard 
oil will answer nearly as well : the oil forms a bland, soothing, not easily 
evaporating coating to the sores, while the lime water is unirritating, and 
3'et furnishes just enough stimulation to save what can be saved and hasten 
the removal of parts already dead. 

The best method of applying the oil is to soak pieces, not more than 
eight inches square, of patent lint, Canton flannel, or even old linen or 
cotton goods, in the mixture, and having laid the dressing thus prepared 
on the parts to be covered, to apply accurately over the whole oiled silk : 
this prevents evaporation, and at the same time secures much greater clean- 
liness than can be obtained in any other way. 

Should the burn be of the first degree, or even of the second, provided 
the vesication were not very extensive, I should suppose, lOn theoretical 
grounds, carded cotton might be a good application, as recommended by 
several surgeons, among others, by Dr. Anderson, ^ by Prof. Cooper,^ and 
by Mr. Newnham and Dr. Black. ^ 

Even in these cases I should be disposed to cover the parts thoroughly 

' 'Glasgow Medical .Journal, for May, 1828. 

2 Medical Times, December 11, 1847. 

3 Provincial Medical and Surgical Journal, February 9, 1848. 



1862.] 



AsHHURST, Burns. 



85 



with the carron oil before applying the cotton. Where, however, the parts 
are more deeply involved, rendering suppuration inevitable, I should very 
much prefer the dressing by means of patent lint and oiled silk. 

Although I have not myself used cotton, I am familiar with its applica- 
tion in the hands of others, and I have not observed from its use the great 
relief from suffering which Dr. Anderson considers one of its principal 
advantages. If cotton be used it should be carefully prepared ; as met 
with in commerce it is too apt to contain germs which heat and moisture 
will develop into maggots, than the discovery of which in a sore I can 
imagine nothing more loathsome to the surgeon. 

The dressings should be retained in place by means of roller bandages, 
which are more satisfactory in every respect than sticking plaster. 

The face should be covered with a mask prepared in the same way, and 
having holes cut for the mouth and eyes. It is better to keep the cloth 
over the face wet by frequent reapplication of the oil ; but if this cannot be 
done it may be covered with oiled silk, secured in this case by adhesive 
plaster, for a bandage around the head is unnecessarily confining. 

When the patient is dressed he almost always expresses himself as feeling 
much more comfortable. He should be encouraged to make hearty meals. 
Soup, soft-boiled eggs, light meats, such as chicken, are especially adapted 
to these cases. The bowels are very often constipated at first, and should 
be opened by mild enemata: in the course of a few weeks, however, exhaust- 
ing diarrhoea is apt to set in, and must be controlled by injections of lauda- 
num or black drop. Retention very often, and sometimes suppression of 
urine occurs during the first days. This is particularly to be watched for 
in women, who from modesty are often prevented from making their wants 
known. 

The most universal accompaniment of burns and scalds is extreme thirst, 
and from an injudicious gratification of this desire (in obedience, perhaps, 
to the vulgar impression that water will put out the fire supposed to be 
lurking in the system) arises one of the most unfavourable symptoms, viz., 
sickness of stomach. I am in the habit of allowing small pieces of ice 
to be held in the mouth, or may give small quantities of carbonic acid 
water ; but on no consideration permit more than a mouthful of water to 
be drunk at once. 

When the patient has been comfortably dressed and has sufficiently re- 
acted, he may be considered out of immediate danger if the extent of surface 
burnt is not too great. The third and the eleventh are often spoken of as 
being critical days, and certainly death is very apt to take place about these 
periods from hypostatic congestions and effusions upon lungs or brain, from 
tetanus or other unavoidable complication. After reaction, if the patient 
eats and sleeps well, is quiet, and does not vomit everything he swallows, 
he may be considered as in a very favourable condition. If, on the other 
hand, he become violently delirious, tossing off" the bedclothes, and even 



86 



AsHHURST, Burns. 



[July 



tearing the dressings from his own sores, instantly rejecting whatever he 
eats or drinks ; and thus, while taking no nourishment, exhausting himself 
in every way, his chances of life are very much diminished. 

The delirium of burns more closely resembles that of mania-a-potu than 
anything else. It is in fact delirium tremens, the trembling delirium, with 
the same cold clammy sweat, running pulse, incessant motion of the hands 
and feet, glaring eye, strange and frightful delusions, whispering voice, 
piercing shrieks, persisting wakefulness, and too often sudden death, which 
are so sadly characteristic of the drinking mania. 

And the treatment is the same : brandy, opium, lupulin, valerian, and 
the whole category of nerve stimulants ; upon these we are to rely as our 
only means of saving life. 

The local treatment in this the second stage of burns must depend on 
the condition of the surface. And it is most important that the sores 
should be dressed as seldom as possible. 'Now this is not lazy surgery, but 
the contrary is meddlesome practice. I have known men calling themselves 
surgeons dress their unfortunate patients three times in one day, and claim 
credit for their zeal. This is all wrong ; the first dressing should not be 
disturbed till absolutely saturated with the discharges ; after this the harm 
of exposure entailed by a redressing will be less than that caused by the 
presence of so offensive a mass as the old dressing has become. 

I have generally found it necessary thus to renew the dressing after two 
days, and thenceforward every other day it will be usually proper to dress 
our patients entirely anew. I would reprehend the practice of dressing 
half a patient's sores one day, and half the next ; this leaves them always 
dirty, and yet always exhausted by the fatigue of being dressed. As soon 
as the slough has come away from any part, I remove the carron oil or 
whatever dressing has been applied at first, and make use of simple cerate 
spread upon patent lint. For this may subsequently be substituted the 
carbonate of zinc cerate, or the unguentum zinci oxidi, according to the 
nature of the granulations. 

In washing burns, after removing the soiled dressings, and previous to 
applying the clean, great care must be exercised. 

The water should be at least at the temperature of the room ; better 
warmer than colder ; the room itself should be warm. I always, before 
dressing a burnt case, shut all the windows and doors and open the register. 
Care should be taken not to touch the raw surfaces with the sponge used 
in washing ; the granulations are very sensitive and bleed easily. On the 
other hand, the new skin surrounding the sore should be carefully wiped 
free from all the discharge which accumulates upon it ; for it is important 
for the patient's health that this skin should exercise as fully as possible its 
exhalant powers. For the same reason, in applying the dressings no more 
than the part really sore should be covered, for to cover the new-formed 
skin renders it useless. 



1862.] 



AsHHURST, Burns. 



When granulation and cicatrization have begun, it is advantageous at 
each dressing to stimulate the sores by gently squeezing from a sponge a 
little whiskey over the healing surface. This is very painful, but if the 
dressing be instantly applied the suffering is only momentary. In the latter 
stages of burns of the fourth degree and deeper, the sore presents the 
appearance of an ordinary healthy ulcer ; here touching the edges with 
lunar caustic in substance is very useful in promoting cicatrization. Of 
course in this the third stage of burns care must be taken, by the use of 
suitable splints and bandages, to obviate the unsightly contractions which 
are apt to follow burns affecting more than the mere surface. 

The constitutional treatment during the third stage must be the same as 
would be proper during any extensive suppuration, from whatever cause. 
I cannot agree with Kentish in recommending low diet and purgatives 
during this stage of burns. The best food the patient can get, stimulus 
graduated according to his condition and the extent of surface suppurating, 
and the administration of tonics, I think give a much better chance of 
recovery than the opposite treatment. I generally give ten drops of the 
niuriated tincture of iron with one or two grains of the sulphate of quinia 
or of cinchonia three times a day, the alkaloid being converted into a soluble 
preparation by the addition of sulphuric acid. If exhausting night-sweats 
supervene, I have found advantage in the use of the elixir of vitriol, or the 
nitro-muriatic acid. Opium throughout is a very valuable remedy, though 
less required in the later than in the early stages. 

The various complications which arise in the treatment of burns and 
scalds must be met secundum artem. Coma, which sometimes occurs in 
the early stage, of course forbids the use of opium. Tetanus, which coming 
on in these cases is very apt to be fatal, may be treated with the Cannabis 
Indica. This remedy I have given with success, in the dose of one grain 
of the extract every two hours. 

Burns are the opprobrium of surgery, and will always continue to be so, 
under whatever treatment; but I firmly believe the mortality might be much 
diminished, could the rules which have been impressed upon my mind by 
sad experience be made equally clear to every practitioner. 

I. "We must look first to the general condition of our patient, and only 
secondarily to the local mischief done; and while many topical applications 
answer equally well, we must look upon the constitutional treatment as all 
important. Many a poor girl's life has been lost by not having been given 
enough to eat, and by brandy and opium being withheld, and the stomach 
deluged with floods of cold water instead. 

II. A burn is essentially a disease of depression, not of excitement. 
Even the violent delirium is but simulative of excitation, and the remedies 
here again are food, brandy, and opium. 

III. There is nothing to be eliminated ; no "fire to be drawn out." All 



88 Packard, Treatment of Fractures of the Femur. [July 

that we have to do is to strengthen nature inwardly, protect her from the 
assaults of cold air and other enemies without, keep the functions regular, 
and meet complications as they arise. 

IV. Although we know that a large proportion of our cases will cer- 
tainly die, we must not give up any one till absolutely in articulo moriis. 
But we should never give a positively favourable prognosis iu any case, 
however slight it may appear, until at least the first and second stages have 
passed by. 

Y. In no cases is decision more called for than in these : the patient may 
die while the vacillating surgeon is making up his mind what to do. Act, 
and act quickly; should our patients recover, their gratitude and thankful- 
ness will amply repay us for our trouble and anxiety; should they die, the v 
consciousness that we have done all that human skill could do, will prevent 
our making that, to the physician, most dreadful reflection, that to our own 
ignorance or neglect have the lives of our patients been sacrificed. 

Philadelphia, April, 1862. 



Art. YI. — On the Employment of India-rubber in obtaining Continuous 
Extension in the Treatment of Fractures of the Femur. By John H. 
Packard, M. D., of Philadelphia. (With a wood-cut.) 

So many contrivances for the treatment of fractures of the femur are 
already before the profession, that it would almost seem as if every possible 
expedient, every imaginable form of apparatus, had been resorted to. And 
yet the results obtained are not satisfactory, nearly all surgical writers 
confessing that an inconvenient degree of shortening of the limb almost 
invariably ensues. The reason assigned for the occurrence of this sequela, 
in cases where there is no loss of bony substance, is the contraction of the 
muscles, which cannot be, or, at least, is not, overcome. 

Whole pages might be covered with quotations to prove that this is the 
great difficulty in treating fractures of the femur. Mr. Syme, of Edinburgh, 
is, I believe, the only eminent surgeon of the present day who considers 
extension to be useless in such cases, and his results, as published,^ are too 
favourable to be implicitly received as true. 

Now when we glance at the vast array of screws, bands, buckles, and 
other devices for "keeping up extension," it becomes interesting to ascer- 
tain why it is that the end is not after all answered. In most cases, if the 
surgeon is called at once, he can restore the limb to its normal length by 

' Observations in Clinical Surgery. By James Syme, Professor of Clinical Sur- 
gery in the University of Edinburgh. 1861. 



1862.1 T^j.r. KARD, Treatment of Fractures of the Femur. 



89 



pulling upo\d cr ether being administered if the muscles are very powerful, 
or are spasmcaically contracted. And immediate reduction is probably 
performed by the great majority of surgeons, notwithstanding the statement 
of some authors that no change takes [)lace at the seat of fracture for eight 
or ten days. It would certainly be strange if the muscles, left to themselves, 
did not shorten, so as to produce, maintain, or increase overlapping of the 
fragments. 

But if the force applied to keep the limb at its normal length were suf- 
ficient, and the apparatus did not yield to the tonic or spasmodic action of 
the muscles, it is plain that shortening could not occur. Whether such an 
absolutely unyielding tension could be borne by the patient, or whether the 
necessary pressure would not be too much for the skin, we need not now 
inquire. As soon, however, as the apparatus stretches in any part to any 
degree, in just that degree is the extension done away with. 

In view of these difficulties, I would call the attention of surgeons to the 
value of India-rubber as a means of making steady and uniutermitting trac- 
tion, such as is needed in the treatment of fractures of the thigh. My own 
use of it has been limited to one case, which I will presently detail. Let 
me first, however, cheerfully acknowledge my indebtedness for the idea to 
Mr. Barwell, who describes and represents, in his late work on " Diseases 
of the Joints," an elastic "accumulator" used by him in the treatment of 
hip-disease.^ 

John E., aet, 18, was playing with some other boys, when he in some 
way struck his right thigh against the shaft of a wagon, with such force 
as to break the bone at about the junction of the middle and lower thirds, 
I saw him an hour or two after the accident, which took place on Sunday 
afternoon. There was no difiBeulty in defining the injury, at a glance, from 
the deformity, helplessness, and shortening of the limb. His temperament, 
naturally irritable, had been rendered more so by an injudicious bringing 
up ; he was therefore impatient of pain or restraint, and almost any treat- 
ment was likely to prove irksome to him. 

. Placing him in bed, I laid the limb on a pillow, and fastened his shoul- 
ders to the upper cross-piece of the bed-frame by means of a towel folded 
cravat-wise and passed under his back, the ends coming up in front, counter- 
extension being thus made from the axillae. Extension was made by ap- 
plying adhesive plaster in the usual way, and then hanging to the bight of 
the band a couple of flat-irons, weighing together about ten pounds. 

No other mechanical treatment was employed for several days, the limb 
remaining comfortable and in proper position. Meanwhile I had a pair of 
splints made like those of Desault as modified by Physick, except in the 
arrangement for extension. 

^ I am aware tliat Dr. Gurdon Buck, of New York, in describing his mode of 
treatment by means of a suspended weight (xim. Med. Times, March 30, 1861), 
suggests the use of an India-rubber band passing over the pulley, so as to combine 
elasticity with the extension ; but, with all deference to that able surceon, I can- 
not see how any advantage is gained, if the weight is properly regulated, by such 
an arrangement. 



90 



Packard, Treatment of Fractures of the Femur. 



[July 



On the inner side of the long outer splint, at its lower herremity, was 
fastened a solid block of wood, 2|- inches in thickness eacn way, and as 
wide as the splint at that part. The middle portion of the block was now 
sawed out, with the corresponding part of the splint, so as to leave a space 
for a pulley, the axis of which ran through the middle of each lateral part 
of the block. This pulley, 2 J inches in diameter, was thus so placed that 
the extending band would play in its grooye. 

I had procured, at an India-rubber store, a day or two previously, a 
''chest-expander," consisting of a round cord of gum-elastic, a little more 
than half an inch in diameter and about fifteen inches in length, having at 
either end a handle placed transversely. From 
this I had had the handles removed, substituting 
at one end a square, flat piece of wood to be 
received into the bight of the extending band of 
adhesive plaster, while at the other end was 
placed a ring, to which was sewed a small flap 
of leather. These arrangements will be readily 
understood by reference to the annexed cut. 

Applying the apparatus in the usual way, I 
brought the India-rubber cord into the groove 
of the pulley, and drawing upon it until it was, 
in my judgment, tense enough, I tacked the 
leather flap to the outer side of the long splint. 
The boy made no complaint of the severity of the 
traction upon his limb, although it was if any- 
thing greater than that usually made with inex- 
tensible bands. From this time forth the mus- 
cles were steadily drawn upon, night and day, 
by the contractile force of the India-rubber; and 
when he at last got out of bed, he could not, 
standing on his left foot, perceive any difference 
between the two limbs in regard to their length. 
He has now (April 2d) been walking about, first 
on crutches and then with a cane, for more than 
eight weeks, and has not the slightest perceptible 
limp. Accurate measurement is impossible, the 
muscularity and plumpness of the boy's figure 
masking the bony points of his pelvis : but as 
far as the degree of shortening can be estimated, 
it is a scant half-inch. 

The above method, although it seemed to me 
to answer the end perfectly in the case detailed, 
might doubtless be improved upon. For instance, 
it has been suggested to me to substitute a strap 
passing through a buckle for the leather flap 
tacked on to the outer side of the long splint. 
Perhaps it would be as well to let the extending band itself play over the 
pulley, the India-rubber cord being stretched along the outside of the splint. 
Another way would be to let the India-rubber cord terminate in a ring at 
either end (a plain, double loop would answer, if of sufficient strength), the 



1862.] Christian, Epidemic Relationsbip of Zymotic Diseases. 91 

extending and counter-extending bands being tied, the former to the lower, 
and the latter to the upper ring. 

Whatever plan is used, the surgeon must remember that continuous 
stretching weakens the gum-elastic. It is better to have a very thick and 
strong band or cord than a thin one, as in the former case the force can be 
equally well-regulated, and is far less apt to be weakened by time. The 
pulley is absolutely essential, unless the extension is direct, which would 
require a splint of inordinate length. Two or three inches of the India- 
rubber cord should be free between the adhesive plaster and the pulley, in 
order to make the elastic force operative. 

Besides the usual mode of making counter-extension by the stuffed fillet 
in the perineum, commonly known as the perineal band, other plans, as is 
well known, have been proposed. Dr. David Gilbert, of this city, recom- 
mends the use of adhesive plaster, applied around the upper part of the 
thigh. Dr. Hartshorne has invented an apparatus in which a block fast- 
ened between the two splints is fitted to receive and bear against the tuber 
ischii. Other plans have from time to time been brought forward for fixing 
the upper part of the apparatus against various points in the bony pelvis. 
I^ow, the chief difficulty in regard to counter-extension is that of avoiding 
excoriation from pressure. But, as a matter of course, the elastic element 
in one portion of the chain would give spring to all the rest, so that any 
pressure would be made more tolerable. On the other hand, in case of 
stretching of the adhesive strips, or any other material used for counter- 
extension, the India-rubber cord should be made so tense as still to maintain 
its traction on the muscles. 

It is probably unnecessary to go into any argument to prove that the 
weight suspended to the foot acts on the same principle of continuous ex- 
tension ; and, therefore, that this plan may be resorted to when the other 
is for any reason inconvenient or out of the question. A pulley for the 
cord to run over is an important advantage, although not essential, when 
the weight is used. 



Art. VII. — On the Epidemic Relationship of Zymotic Diseases. 
By E. P. Christian, A. M., M. D., Wyandotte, Mich. 

Observation seems to have determined conclusively that there exists a 
certain relationship, or consanguinity, using the word as correctly as in its 
popular acceptation, between some diseases of an epidemic character. As 
it regards erysipelas, and a form of puerperal metritis, this relationship 
seems to amount to a pathological identity ; and less determinately, but 



92 Christian, Epidemic Relationship of Zymotic Diseases. [July 



with more than plausibility, may arguments be adduced iu favour of the 
same conclusion respecting other epidemic diseases. 

Inquiries iu relation to the pathology of epidemics, tend greatly towards 
proving the fact of the unity of zymotic diseases in their origin, or epidemic 
cause; observation, therefore, becomes not so exclusively directed towards 
establishing their differential diagnosis, as to studying the generic points 
of those possessing, apparently, less of family similitude. 

Not only has similarity of pathological manifestations challenged obser- 
vation in some of these diseases, scarlatina and erysipelas, for instance, but 
so does especially their epidemic relationship, in the uniformity of their 
sequence and concurrence. 

It has been often observed that certain epidemics either prevail together, 
or follow each other with such uniformity and regularity, that the convic- 
tion of its being the result of something more than mere accident is irre- 
sistible ; that there are indeed definite laws governing these phenomena, 
and it is more than probable that these laws, when known, will point out 
to us, not the pathological identity of these diseases, but an identity of 
epidemic cause : the difference of resulting pathological phenomena, consti- 
tuting the specific disease, being determined by other intrinsic or extrinsic 
circumstances. 

In confirmation of this statement, I cite the common concurrence of 
erysipelas and puerperal fever ; of scarlet fever and measles ; of erysipelas 
and scarlet fever ; the latter with typhoid fever also, and probably with 
diphtheria too : all as modified forms of the action of the same zymotic 
poison, or modified zymosis from the same epidemic cause. 

Opinions not sustained by facts are of little weight, and we confess to 
having been impressed, chiefly, by common observation, without having 
made any large collection of facts bearing on the subject ; still we adduce 
the historical concurrence and succession of epidemic diseases iu this viciniiy, 
during the past six months, as confirmatory of this law, so far as it goes, 
believing that accurate observation will continue to adduce similar evidence. 

In August or Septeml)er of the past year, rubeola appeared in this and 
neighbouring villages, prevailing epidemically, as it did also near other 
large sections of country. The general presence in the atmosphere of the 
zymotic cause was strongly indicated in this neighbourhood by the number 
of those attacked. Very few of the unprotected population escaped ; yet 
it operated with comparatively little virulence, as out of an aggregate of 
more than one hundred and twenty cases, not one death occurred that could 
be fairly charged to this disease ; the only two cases in which it so termi- 
nated, were both children previously afflicted with chronic ailments, which 
became so much aggravated as to result in death. 

Before Christmas, measles, in an epidemic form, may be said to have 
subsided, more probably from want of subjects on which to act, than from 
a subsidence of the epidemic cause, it being never entirely absent from the 



1862.] Christian, Epidemic Relatioiisliip of Zymotic Diseases. 93 



village until March, sporadic cases occurring occasionally, in concurrence 
with other diseases, which we are about to mention. 

In December, while the measles was at its height, I was called in attend- 
ance on cases of unequivocal and severe diphtheria, in the neighbour- 
ing village of Ecorse, distant two miles from Wyandotte ; this disease 
prevailed also, in a virulent form, and quite as extensively. In its outbreak 
it invariably attacked those who were just convalescent from measles. Not 
a single case of scarlatina had occurred in the village up to this time, though 
there were some subsequently, before its entire disappearance. 

Just at this time, while in attendance on diphtheria at Ecorse, a virulent 

anginose affection occurred in Lizzie C , a child of seven years, in this 

village, who was just convalescing from measles, and the case bearing every 
resemblance to those I was attending at Ecorse was pronounced the same. 
There was not the slightest appearance of an eruption, nor any desquama- 
tion of the surface, a fact I mention, because in some which occurred subse- 
quently, where there was no appreciable eruption, desquamation took place 
during recovery. During the convalescence of Lizzie, a younger sister, also 
just recovered from measles, sickened, and in three days died, with all the 
symptoms of unequivocal scarlatina anginosa. Several other children in 
the same family sickened with well-marked scarlatina, and recovered. 

From this family, scarlet fever, of an intense anginose and malignant, 
variety, spread rapidly into those of friends and neighbours, and gradually 
over a large part of the village, until, by April, an aggregate of more than 
eighty cases came under observation, with ten deaths, all occurring among 
very young children. The disease, in its onset, continued to attack those 
lately recovered from measles, and at first, also, electing those for its victims 
who had in any way been exposed to contagion from the sick, but eventu- 
ally seizing upon some who had been most carefully and vigilantly guarded 
from it, and, on the other hand, strangely passing by those who had been 
repeatedly exposed. 

All through the progress of this epidemic, there were cases of diphtheria 
occurring occasionally, of a character well marked, and very distinct from 
the anginose affection of scarlatina, until about the middle of March, this 
disease may be said to have reached the character of an epidemic also. It 
prevailed chiefly among adults, or those of fifteen years and upwards, but 
not exclusively so; the scarlatina as generally selecting children, though 
sometimes seizing upon adults. In families where the scarlatina prevailed 
among the children, the adults were especially liable to an anginose affec- 
tion, varying in intensity in individual cases. The diphtheria attacked 
those who had had scarlatina in infancy. None passed through the two 
forms of the disease. The former prevailed most amongst those who had 
not been exposed to scarlatina, and was as likely to seize upon a single 
member of a family as upon several, the reverse being the case with scarla- 
tina. 



94 Christian, Epidemic Relationship of Zymotic Diseases. [July 

And ijovv I will briefly detail the peculiarities of some individual cases, 
exhibiting another zymotic element present as an exciting cause, or else 
showing still other modifications of zymotic disease from the epidemic con- 
stitution of the atmosphere. 

The following case is cited as a type of many which occurred during the 
scarlatinal epidemic : — 

About the first of February, the babe of Mr. Dewitt, aged four months, 
sickened with scarlet fever, three older children in the same family just con- 
valescing from the same disease, which they had had severely. In the babe, 
the enlargement of the submaxillary glands was very great, though not so 
large as in two of the older children who recovered. It was of an erysipe- 
latous appearance, and instead of the general efflorescence on the surface, 
there were discrete patches of erysipelatous swellings scattered principally 
over the limbs. This child died on the second or third day, from the 
intensity of the blood poison, and not apparently from any local compli- 
cation. 

Tebruray 16th, I was called to see M. Drunnan, aged twelve. The street 
on which he lived had been the hot-bed of scarlet fever, over twenty children 
having had it in a severe form, within a space of three hundred yards. This 
boy had never had the scarlet fever, but had recently recovered from measles. 
I found him with high continued fever ; great general disturbance of the 
organic functions ; and erysipelas extending from the ankles over a large 
part of both legs. He recovered by resolution in about ten days. Other 
children of the family subsequently sickened with genuine scarlet fever. 

About the same time I attended Mr. Eva, who had simply run a small 
splinter into his finger, from which erysipelatous inflammation extended 
half way up his forearm, and sloughing of a large part of the cellular tissue 
of his finger took place. 

M. Twaddle fell, and struck the back of his hand, not violently, yet ery- 
sipelas set in, and sloughing of much of the cellular tissue ensued. 

.Other cases of a similar nature occurred, not necessary to detail. 

In the convalescents from severe attacks of scarlet fever, furuncles and 
abscesses were common, not merely about the glands of the neck, but in 
the chest, back, and abdomen. All such cases recovered without any sub- 
sequent relapse, as did also those generally in whom the eruption took the 
form of minute vesicles, covering the scarlet efflorescence like sudamina. 
These were successful efforts on the part of nature to eliminate the morbific 
matter or poison from the system. 

In proof of the coexistence of still another allied form of disease, I will 
now detail the two following cases : — 

March 3d, Mrs. A. was confined with her fourth child. March 8th, Mrs. 
II. was prematurely delivered of her first, at the eighth month of ntero- 
gestation. In the latter case there was ample cause for all subsequent 
developments, from the fact of premature labour having been induced by a 
fall, and laborious exertion in stowing away a load of hay. The labour was 
exceedingly severe and tedious, owing to the narrowness of the pelvis; and 
none biit the services of an ignorant midwife were sought until the last 
stages of labour. The night after the birth of the child she arose from the 



1862.] Christian, Epidemic Relationship of Zymotic Diseases. 95 

bed on the cold floor to administer to the wants of her babe, being unable 
to arouse her attendant. The next morning I found her with intense metro- 
peritonitis. She was bled, with entire relief of pain, and reduction of the 
pulse. In the evening there was increase of soreness again. Leeches were 
applied, and afforded relief; again the disease lighted up with increased in- 
tensity; again bleeding was resorted to ; but the patient subsequently died. 

On the day of this woman's death, acute metritis lighted up in the first 
named patient, Mrs. A., being the twelfth of her own confinement. At the 
same time erysipelas of the integuments about the left eye set in. Leeches 
were applied, and copious flowing from the bites encouraged for several 
hours on the lower part of the abdomen, with entire relief of the metritis, 
and also of the erysipelas. 

It is proper to say now, however, that among a number of other partu- 
rients about the same time, and some of them under unfavourable circum- 
stances, there was nothing to interfere with their normal recovery. 

Now, then, the inquiry suggests itself, is such a concurrence of zymotic 
diseases, which is not at all uncommon, satisfactorily explained by the 
theory of one prevailing epidemic leaving its impress on all concurrent 
diseases, or the epidemic constitution of the atmosphere modifying and 
impressing the prevalent diseases ; or does it not rather indicate a close 
family relationship, or consanguinity between these zymoses, originating 
perhaps from the same epidemic cause, and the specific characters of each 
disease being derived from other, and as yet unknown causes ? 

In conclusion, if the marked pathological dissimilarity in these associated 
diseases is advanced as an argument against the identity of their cause, or 
more correctly, against an intimate causal relationship, we may cite on the 
other hand the marked difference of pathological manifestations arising in 
different individuals, placed under similar circumstances, exposed to the 
same morbific cause, paludal malaria ; the different resulting diseases de- 
pending upon a variety of modifying circumstances. In those exposed to 
the action of this malaria, we may observe the protean forms of miasmatic 
disorders, as numerous, and more varied than those above enumerated. We 
see intermitting, remitting, and continued fevers ; neuralgias, intermittent 
and continued, in a single, or a set of nerves, and other phases of nervous 
derangement innumerable; dysenteries, diarrhoeas, and bilious colics ; Jaun- 
dice; pneumonias, and even cutaneous eruptions, &c. &c. l^ow is it less 
rational to suppose there may be a similar unity of origin of those asso- 
ciated epidemic diseases, than of these endemic disorders whose cause, if 
more appreciable, is certainly quite as intangible. 



96 Johnston, Description of a Pseudencepbalic Monster. [July 



Art. YIII. — Description of a Pseudencepholic Monster. (Genus 11, 
Thlipseucephalus, Isidore G-eoff. St. Hilaire.) By Christopher John- 
ston, M. D., Baltimore. (With three wood-cuts.) 

I AM indebted to ray friend, Dr. J. Dwinelle, of Baltimore, for the 
privilege of making the following observations upon a living Thlipseu- 
cephalic monster, and also a dissection of the abnormal parts. 

A lady in her sixth confinement gave birth to a large, living, male child, 
robust and well-formed in its other parts, but monstrous in the development 

of its head, which, strongly 



plantar surface; its weight 8^ pounds on the second day of its existence. 
The testicles had not descended. 

It may not be amiss to remark that the mother, an exceedingly amiable 
person, was peevish and irritable during her entire pregnancy, which she 
claims to have exceeded the normal period by one month ; and that, at 
about the third month, she received a severe internal injury from a child 
who leaped with force upon her abdomen. 

The foetus presented normally, and the labour, although somewhat 
tedious, was not severe. As soon as born, the child moved its limbs and 
trunk ; its respiration was at once established, and it uttered cries which 
were remarked to be more feeble than those of ordinary children. But, 
although the circulatory and respiratory functions soon became active, the 
countenance remained livid, while yet the rest of the cutaneous surface 
assumed a fresh rosy tint. 

The ready movements of the mouth attracting attention, the mother was 
besought to apply her offspring to the breast ; l)ut nothing could overcome 
her repugnance to nursing "so hideous a monster," whereupon, the nurse 
essayed -successfully to feed the child with sugar and water administered 
with a spoon. 

The birth occurred on the 19th of July, at 11 o'clock A. M., and I first 
saw it on the 20th, at 6 P. M., in the interval between which hours urine 



Fig. 1. 



bent backwards, was deficient 
in both bone and natural in- 
tegument above a line pass- 
ing over the orbital plates of 
the frontal, the petrous por- 
tion of the temporal, and 
along the lateral sinuses of 
the occipital bones. The 
shallow cranial cavity was 
occupied by a flat scarlet 
tumour, 2J inches in length 
by in breadth, varying 
from J to I of an inch in 
thickness, and which was 
lobulated so as to suggest 
the idea of hemispheres and 
cerebellum. Fig. 1. 




The length of the child 
was 19 J- inches, the umbilicus 
beins" at 10 inches from the 



1862.] Johnston, Description of a Pseudencephalic Monster. 



97 



and meconium had each been voided once. The radial pulsations could 
not now be counted, but the heart's rhythm was regular and even, and its 
beatings numbered 160 in the minute. Respiration, 44 per minute; in- 
spiration at times suspirious, but generally sobbing; expiration slightly 
hoarse, yet effected in a single effort. The thoracic and abdominal respira- 
tory movements were full, although somewhat laboured. Temperature of 
the body cool ; that of the face conspicuously so. 

The child moved its limbs, and grasped what it touched with the hands. 
It obeyed the calls of nature, partially closed the eyelids, which presently 
relapsed into their former half-opened state, but it appeared to be, and 
doubtless was, unconscious ; and the ocular globes, which diverged a 
little in strabismus, as well as the pupils, remained immovable even when a 
lighted candle was brought into close proximity to them. 

When undisturbed the little creature now made no effort to alter its 
position ; it shrank, however, if flies crawled over its head, and started 
almost upright whenever the tumour, especially the posterior part of it, 
was touched. Yet it is worthy of remark that pressure exerted upon the 
same part was productive of very inconsiderable effects, although, at the 
moment of contact of the finger, sensibility seemed painfully heightened. 

At the period of my visit mentioned above, the child was reported to 
have lost much of its energy, but it could still practise suction upon a finger 
introduced into its mouth, and it swallowed a bland fluid which I adminis- 
tered in a spoon ; notwithstanding the attendants were unwilling to satisfy 
the wants of so forbidding a creature. It continued to grow feebler and less 
livid until about one o'clock A. M. of the 22d (62 hours), when the respi- 
ratory act was arrested and renewed several times, and it stretched out its 
limbs and presently expired. 

Appearance of the body nine liours post mortem. — Face livid ; tumour 
had subsided somewhat, and was of a less brilliant color ; the rest of the 
body was of a yellowish hue. 

Head. — A careful dissection revealed the following, viz : The three red 
lobular masses, upon being opened, were found to consist entirely of spongy 
vascular substance surrounding a considerable number of cysts or loculi 
containing a dark amber-coloured fluid. Upon removing the remaining 
portion of the occipital bone, namely, the part below the inner protuberance, 
and which was entire, laying bare the atlas and dentata, the arches of 
which were deficient, and cutting away the arches of the other cervical 
vertebrae, the dura mater was found to be much thickened, and to present 
the appearance of a network including a serous fluid in its meshes. The 
medulla oblongata being exposed, the pia mater surrounding it was of a 
deep-red colour and thickened, and was lost in the tough substance of the 
tumour. Indeed, like the dura mater just noticed, the pia mater, in this 
situation as well as in the tumour, which was evidently an abnormal de- 
velopment of this expansion, offered all the characters of an erectile tissue. 

The medulla spinalis was perfectly normal, as was also the medulla ob- 
longata, which terminated the nervous tract anteriorly. There were no 
hemispheres nor trace of nervous matter in the red lobes, but in the quasi 
cerebellar lobule a little node or mass as big as a pea was found in a cyst. 
The pons was absent ; but upon the upper extremity of the medulla, poste- 
riorly lay a little roundish mass of nerve-substance of a dark purplish -red 
colour, measuring y\ of an inch in diameter. 

Two semi-fibrous cords passed separately, one from either side of the 
base of the red tumour, through the ontic foramina of the sphenoid, and 
No. LXXXYIL—JuLY 1862. ' 7 



98 Johnston, Description of a Pseudencephalic Monster. [July 



represented the optic nerves. But while there was no sug:gestion of a chi- 
asma or of nerve-matter in the cords behind the sella turcica, it is espe- 
cially worthy of note that in front of the posterior clinoid processes the 
cords each contained a little bundle of nervous filaments, which were con- 
tinued into the orbits. These nerve-fibres were carefully studied with the 
aid of the microscope, and they corresponded in all particulars to those 
taken from the optic nerves of a stillborn but perfectly formed child. 

The first nerve was wanting ; the second has just been mentioned ; the 
third and fourth were also absent ; the fifth nerve arose out of the outer 
corner of the extremity of the medulla, which was very red at this point. 
The Gasserian ganglion and the underlying motor bundle were distinctly 
recognized, and the three branches of the fifth traced to their foramina of 
exit. Figs. 2 and 3. 



The sixth was perfect in course and appearance, and seemed to be com- 
posed of two filaments in one sheath. 

The remaining six nerves, and also the cervical spinal nerves, were nor- 
mal, except that the hypoglossal had a very low apparent origin. 

The pituitary ''gland," or, rather, a reddish body representing it, occu- 
pied the sella turcica. 

No farther dissection was allowed. 

In reviewing the above statements the reader will at once perceive that 
the strabismus depended upon' the existence of but a single motor nerve in 
the orbit ; for when, animated by the sixth nerve, the external rectus had 
once contracted, the globe remained everted on account of the total absence 
of antagonistic power to restore equilibrium. 

With regard to the movements executed by the infant, it must be ad- 
mitted that they were purely reflex and involuntary, for although all the 
sensitive nerves of the body and head were in normal condition (if we ex- 
cept the absent relation of the fifth nerve to the tuber annulare), the entire 
cerebrum and pons varolii were wanting, and of the cerebellum there re- 
mained only a diminutive rudimentary button fastened down upon the pos- 
terior surface of the medulla, which might exert a pronominal co-ordinating 
influence upon muscular motion. It is true that irritation of any sort 
applied to the tumour, particularly the posterior surface, which was some- 
what chafed as it was thrown back against the pillow, occasioned au 



Fig. 2. 



Fig. 3. 




Medu'la oblongata ; Anterior view ; 
Natural size. 



Medulla oblongata ; Posterior view ; 
Natitral size. 



1S62.] 



Kerr, Hospital at Canton. 



99 



immediate start ; but we must discriminate betwixt this convulsive effort, 
in which the loill could not possibly be involved, and the " endeavour by 
voluntary movements to escape from a painful irritation, which, as an 
evidence of sensitiveness to external impressions, is still possible when, after 
ablation of all other parts of the brain, the tuber annulare and medulla 
oblongata are respected." In the present instance, Nature had paused at a 
condition in the human subject which art has striven to reach in lower 
animals ; and that, too, without those embarrassing side consequences with 
which scientific mutilations are too frequently attended. 



Art. IX. — Cases treated at the 3Iedical 3Iissionary Societi/s Hospital 
at Canton, China. By John G. Kerr, M. D. (Communicated by Prof. 
S. D. Gross, M. D.) 

Of the surgical cases presented for treatment at the hospital in Canton, 
the most important are those requiring operations for the removal of stone 
in the bladder. There are no statistics to show how common this affection is ; 
but that it is of frequent occurrence may be inferred from the fact that not less 
than fifty cases are seen annually at the two missionary hospitals in this city. 

It is unnecessary to enter into a discussion of the causes which produce 
calculous diseases; but it may be remarked, as bearing on the subject, 
that, as tea is the universal beverage of the Chinese, they do not drink 
water until it has been boiled, and the lime which it contained is thereby 
precipitated to a greater or less extent. It is a very rare thing for a China- 
man, even of the poorest classes, to drink cold water. In this country, 
therefore, the disease cannot be attributed to the use of water impregnated 
with the salts of lime. 

It is a remarkable fact that urinary calculus has not been met with in any 
other part of China than Canton Province. Dr. Lockhart, of Shanghai, 
and Dr. McCartee, of Ningpo, who have practised among the Chinese for 
about twenty years, have informed me that they have never met with a case. 
Tliat the disease exists in other parts of this vast empire is not unlikely, 
but it remains for future observers to discover the localities. 

The first operation for stone in the bladder was performed in July, 1844, 
by the Rev. P. Parker, M.D., who was the founder of the Medical Missionary 
Society's Hospital. Up to the end of 1851 Dr. Parker had operated on 
30 cases, only two of which were fatal. He had, I think, half a dozen other 
operations which have not been published. In 1854-56 Dr. W. G. Dick- 
son operated on nine cases at the Medical Missionary Society's hospital. 
One case was fatal. About 39 cases have been operated on at the Hospital 
of the London Missionary Society in this city, of which nine have died. 
The operators were three English surgeons and one Chinese surgeon edu- 
cated in Edinburgh. 



100 



Kerr, Hospital at Canton. 



[July 



Remarks. 


Lithotrity. 
11th day. 

Opium sraolvcr, 

2d day. 
Lithotrity, 

Opium smoker. 
Two stones. 

Encysted. 

Two stones. 


Result. 


o o o 

o--i2o.^^.. -ZZ o 

C P^ C P5 


Weight. 


W O !M O (r<l O O M oV"i'0 O CI rH O r-n'r-t !— HOOr-HOOO 


. Diameters. 


a 

I— 1 S^CJr-iCqr--rq — r-r-^SSlr— It— i (7^1— ((Ml— C^i— 4C^rOl— Ir—I 


Chemistry. 


Uric acid 

Phos. lime 
Uric acid 
Oxalic 
Uric acid 

<< 

Phos. lime 

Uric acid 

Triple phos. 

Phos. lime 
Uric acid 


Date of Operation. 


May 23, 1856 
Oct. 10, " 
Oct. 17, " 
Nov. 29, 1859 
Dec. 2, " 
April 10, 1860 
July 5, " 
July 5, 
July 27, 
Aug. 11, " 
Sept. 18, " 
Nov. 15, " 
Dec. 4, " 
Dec. 11, " 
Dec. 11, " 
April 8, 1861 
April 8, " 
May 17. " 
Aug. 12, " 
Sept. 9, 
Sept. 9, " 
Sept. 30, " 
Oct. 30, 
Oct. 30, " 
Nov. 4, " 
Nov. 13, 
Dec. 30, " 


Duration. 


CO . , • . M . 

P -.It- C >^ 
1— i ^ rH —i 1—1 


Occupation. 


I^abourer 
Farmer 

Shopkeeper 

Shopkeeper 
Carpenter 

Labourer 

Shopkeeper 
Tile-maker 

Paper dealer 

Farmer 

Wire-maker 

Boatman 

Farmer 

Small trader 

Farmer 

Shopkeeper 

('arpenter 

Farmer 

Small trader 


6 

c 


Sanshwui 
Kauming 

Canton 

Tungkwan 

Nanhai 

Canton 

Pwanyii 

Szhwui 

Shauhing 

Tungkwan 

Sinhwui 

I'wanyli 

Szhwui 

Sinhwui 

rieungshan 

Fuhshan 

Tungkwan 

Pwanyii 

Tsingun 

Pwanyu 

Nanhai 

Szhwui 

Tungkwan 

Sanhing 

Pwanyii 


ta 


o GO to o c~ c- c-i — J iQ — 1 X' 1— d r— cc ^ C5 ^ r-H o ^ L— 1— 1 ' 


No. 





1862.] 



Kerr, Hospital at Canton. 



101 



The above tabular statement includes all the operations for stone 
performed by myself up to the end of 1861. It will be noticed that no 
cases occurred in 1857-58. This was owing to the fact that the operations 
of the hospital were interrupted during those years by the war betw^een 
England and China. 

A few remarks on some of the cases is all that it is necessary to add to 
the facts contained in the tabular statement. The majority of the patients 
reside at distances of less than fifty miles from Canton. A few lived far- 
ther away, and one or two resided at a distance of about one hundred miles 
from the capital of the province. 

The lateral operation has been performed in all the cases, except two, in 
which lithotrity was employed. This operation would be resorted to more 
frequently in suitable cases, but that patients are not willing to stay the 
length of time necessary for its completion. The stone in Case No. 23 
would have been crushed but for an error in measuring it, although this 
•jvas carefully done before operating. The case was an excellent one for 
crushing, but the recovery of the patient after being cut was slow and un- 
satisfactory. 

In Case No. 3, the stone was covered with a deposit of crystals, which 
made its surface very rough. The bladder was no doubt extensively dis- 
eased, as the foreign substance had been in the viscus for so many years. 
There was a large deposit of muco-purulent matter in the urine. Reaction 
did not take place after the operation, and the patient gradually sank from 
irritative fever of a typhoid character. 

In Case No. 10, the operation was followed by an abscess in the left 
internal iliac region, the matter from which was discharged at the incision. 
He lingered for several weeks with but little prospect of recovery, and 
finally returned to his home, about ninety miles distant. About six months 
afterward he returned to the hospital, very much improved in health, the 
abscess having entirely healed, but he still had symptoms of stone. After 
vseveral careful examinations, a small stone was found in the membranous 
portion of the urethra, which had formed, no doubt, during his long illness. 
He declined submitting to any attempt to remove it, and left the hospital. 
In the beginning of the present year he was met with again at the dispen- 
sary in Fuhshan, in the enjoyment of robust health. The small stone had 
))een discharged some months before, and was followed by entire relief of 
all his sufferings. This man complained of inability to discharge semen, 
although erections took place as usual. 

Cases No. 1 and No. 20 were opium smokers. The appearance of the 
latter was like that of a man in the decline of life at 60, although his age 
was only 47. When he first came to the hospital the operation was declined 
on account of his general debility, and the indications of extensive disease 
of the bladder. He returned to the country, and, after spending some 
months in a place more salubrious than his own residence, he came back to 



102 



Kerr, Hospital at Canton. 



[July 



the hospital, with a decided improvement in his general health. The ope- 
ration was undertaken with reluctance, but finally his urgent requests were 
yielded to. The stone had three rough places on its surface which were 
the cause of much irritation of the raucous membrane. One of these rough 
places was so situated as to be in the form of a jagged hook, and in the 
extraction was the cause of much laceration of the tissues. Notwithstand- 
ing all these unfavourable circumstances, the patient recovered slowly and 
left the hospital about a month after the operation. 

In Cases 'No. 24 and No. 25 the stones were unusually rough, and had 
caused chronic inflammation of the bladder, which made the cases very 
unfavourable. The stone in No. 24 was encysted, or so grasped by the 
thickened and contracted coats of the bladder that it was almost impossible 
to extract it, and, after nearly two hours' bard work, I was on the point of 
giving it up, when, at last perseverance was rewarded with success. The 
size and roughness of the stone, in Case No. 25, rendered its' extraction 
very difficult, and about one hour and a half were consumed before its 
removal was effected. In both these cases, great violence was done to the 
tissues of the perineum, both by bruising and lacerating, and this, added 
to the chronic disease of the bladder, rendered the recovery of the patients 
exceedingly doubtful. They both, however, recovered gradually, but slowly, 
without any serious drawback. When they left the hospital, they were stili 
suffering from chronic disease of the bladder, but there was every prospect 
that removal to the country would soon result in perfect restoration of 
health. 

The last case. No. 27, was complicated with stone in the urethra, which 
had caused inflammation and swelling of the penis with ulceration of the 
glans. This stone was about one inch long, by three or four lines in diameter 
at one end, tapering to half that size at the other end. After its removal 
the penis was restored to a healthy state by fomentations, laxatives and 
other means, and then it was found there was urinary calculus. On per- 
forming the lateral operation, two stones, of the same shape and size, were 
removed, and the patient made a favourable recovery. 

No case of calculus in the female has been met with. 

With reference to the treatment after the operation, it may be stated that 
the patient is placed on boards with a thin straw mat — the common Chinese 
bed — and that these boards are separated three or four inches so as to allow 
the urine and feces to be received into a vessel below. No dressing was 
applied to the wound, but frequent bathing with tepid water was practised. 
Each patient had his own attendant, and but little control could be exer- 
cised over the diet. When able to buy it they often took medicine from 
native physicians. 

In one case only was there dangerous hemorrhage, and this happened on 
the fourth or fifth day, in a patient 50 years old. 



1862.] 



FouRGEAUD, Puerperal Uraemia. 



103 



Art. X. — Case of Puey-peral Ureemia. Bv Y. J. Fourgeaud, M. D., of 
San Francisco, California. 

Called upon to attend Mrs. , on the 24th of September, 1861, I 

was informed that she had had several miscarriages, and that her two living 
children were born before the eighth month. I found her face oederaatous, 
and she complained of loss of sight, so that it was difficult for her to dis- 
tinguish persons at a few feet from her, and was unable to read printed 
matter. 

Suspecting from these symptoms that she was under the influence of 
uraemic intoxication, I requested that her urine should be sent to me for 
examination. Having submitted it to the usual test, by fire and acid, the 
result confirmed my fears. An albuminous deposit of more than one-third 
of the quantity of urine submitted to the test settled the diagnosis. 

Having informed her friends of the danger of her situation, I placed her 
immediately under the prophylactic treatment of Braun, hoping thus to 
avoid the imminent peril attending such cases, and especially convulsions. 

On the 27th, I lost all hope for the life of the foetus, its movements 
having ceased, and auscultation revealing no foetal pulsations. Having 
again auscultated her on the following day, with no better result, I felt 
satisfied that the fostus was dead, and so informed her friends. 

She was taken with labour-pains on the 1st of October. At that time, 
although the quantity of albumen in the urine had considerably diminished, 
the amblyopia had gradually increased to such a degree that she could not 
distinguish common objects near at hand. 

I placed her under a moderate influence of chloroform, whenever the 
pains would come on, and, after a few hours, she was delivered of a seven 
months' foetus, which, to all appearance, had been dead for three or four 
days. Her labour was otherwise natural, and passed off without convul- 
sions — a circumstance which I attribute altogether to the prophylactic 
treatment and the use of chloroform. 

The following morning, finding that she had not passed water, I relieved 
her with the catheter. I was then informed that she could not move her 
legs, and, upon examination, I found her paraplegic. The muscles of the 
upper half of the body were altogether intact and performed their function 
naturally. The pulse was rather feeble and excitable. The brain was in 
a normal condition, the intellect perfect, deglutition and articulation good. 
The spine gave no indication of pain until coming to the third lumbar 
vertebra, where pressure was intolerable, there being much tenderness from 
that point to the extremity of the coccyx — the pain being greater, however, 
on the lumbar vertebras. The motor power of both legs was entirely lost, 
sensibility being but partially impaired. Paralysis of the rectum and 
sphincters, with involuntary discharges of feces ; paralysis of the bladder, 
with retention of urine ; amaurosis, the eyesight being almost entirely gone. 
Such was the condition of the patient on the 2d of October. 

On the 3d there was suppression of the lochias (which did not return 
again), fever and great tenderness and swelling over the abdomen, which 
continuing for several days, caused me to fear a metro-peritonitis. How- 
ever, all the inflammatory symptoms and pain gradually subsided under 
treatment. (Abdomen covered with large linseed meal and poppy poul- 
tices ; clysters of the same nature. Diet: milk, tea, and dry toast.) 



104 



FouRGEAUD, Puerperal Uraemia. 



On the 6tb, no change in the paralytic symptoms. The urine exhibited 
a large quantity of mucus, with earthy phosphates, alkaline, highly ammo- 
niacal and so thick and ropy that micturition was often difficult and some- 
times quite impossible through the catheter, until the instrument had been 
cleansed of the secretions which clogged it. Specific gravity of urine 1012. 
The catheter was used three or four times a day, and the bladder was 
washed out daily by freely injecting tepid water into it. The spine and 
lower extremities were rubbed with lin. ammonise, and afterwards with the 
following: R. Tinct. nucis vomicae Jj ; Liq. ammoniae 5ij ; M. pro lin. 
The infusion serpentari^, with the addition of quinine, was ordered three 
times daily; also: R. Acid, benzoic, ^iss; Dec. pareirae 5xvj ; Morph. 
acet. gr. ij. M. A tablespoonful three times a day, with five drops of 
vin. colch. rad. Patient objecting to blister on the spine, stimulating 
liniments were used. A slight running from the bowels having supervened, 
it was checked by starch injections with a few drops of laudanum. 

18th. No important change in the amaurotic and paralytic symptoms. 
Electricity was used on this day for the first time, and continued for several 
days along the spine and legs and over the region of the bladder. The 
urine was free from deposits and mucus ; colour, pale amber, no trace of 
albumen; reaction, alkaline; sp. gr. 1011. 

20th. Sight improved a little, begins to distinguish persons in the room ; 
can move left leg. Bowels are somewhat better under her control, but no 
improvement in the paralysis of the bladder. The retention of urine per- 
sisting, the catheter has to be used. Right leg still completely paralyzed 
and oedematous from knee to foot. Bandaged it up. Sp. gr. of urine 
1012. Colour, pale amber; reaction, acid. No trace of albumen. 

Nov. 1st. Her general health continues to improve. Right leg still 
paralyzed and oedematous. Troublesome cough. Continue treatment ; 
also : R. Syr. scill^, Syr, acacias aa Jj ; Tinct. opii camph., Tinct. vale- 
rianse aa 3iv. M. Take two teaspooufuls in a little water pro re nata. 

22d Since the first the patient has continued to improve gradually, but 
steadily. Her eyesight Tias made such progress that she can now read 
print. The oedema has disappeared, and the paralysis of the leg is con- 
siderably diminished. She can now take a few steps, being supported. 
Yesterday she passed water for the first time since her confinement, without 
the aid of a catheter. Urine, clear, amber colour; sp. gr. lOlT ; no albu- 
men. Her bowels are under her control, and it is only occasionally that 
she has an involuntary passage of feces. The tenderness over the spine is 
now very slight. Continue treatment. One of the following pills daily : 
R. Strychniae gr. j ; Cons, rosag q s. M. Ut fiaut pil. xii. 

2Qth. All the paralytic symptoms much better. Can walk across the 
room without support. Urine, natural; sp. gr. 1018. Has to use the 
catheter only occasionally. 

The patient continued to improve until the month of December, when 
the family being about to remove to their country residence, I recommended 
gentle exercise, the use of sea-water baths, good nourishing diet, with port 
wine and brandy, and Pil. ferri carb. gr. x daily. 

With the exception of an occasional relaxation of the sphincters, under 
fatigue, when she over-exerts herself in walking, the patient has entirely 
recovered. 



1862 j 



105 



TRANSACTIONS OF SOCIETIES. 



Art. X[. — Summary of the Proceedings of the Pathological Society of 

Philadelphia. 

1862. Jan. 22. Singular Lesion of the Urinary Bladder. — Di\ 
Packard exhibited the right lung and the bhidder of a man, set. 25, who 
died in the Christian Street Military Hospital, of pleuro-pneumonia follow- 
ing measles. 

An immense effusion of turbid serum, full of flakes and shreds of yellow 
lymph, distended the right pleura and compressed the lung. The two layers 
of the pleura adhered to one another by means of soft yellow lymph over 
a space about as large as the palm of the hand, at the side. Spots of con- 
gestion, amounting almost to extravasation, were scattered here and there 
through the lung tissue. The mucous membrane of the trachea and bronchi 
was deeply reddened, and the bronchial glands much swollen. Nothing 
abnormal was noticed in the left lung. 

All the cavities of the heart were distended with black blood, partly fluid, 
and partly in soft cnrrant-jelly like clots ; on cutting into the ventricles the 
mass was squeezed up into the incision. Within the pericardium there was 
a small quantity of turbid serum, but no inflammation of the membrane 
could be detected. 

The liver was rather large and fatty, the spleen soft and pale. The pan- 
creas was so soft as to be easily torn, but was rather injected than otherwise. 
The kidneys were pale. 

On laying open the urinary bladder, which was contracted into a very 
small space, there were noticed on its floor several elevations, of various 
.shapes, one crest-like, another broad and flattened, but all presenting aii 
intensely red colour as if inflamed, and one or two looking as if ulcerated. 
The rest of the mucous membrane was perfectly smooth and pale, but a 
large portion of the surface of the urethra was deeply congested. 

Feb. 12. Dr. Packard exhibited a urinary bladder presenting a curious 
analogy to that in the foregoing case, from a man who died of pneumonia 
supervening upon measles, in the Christian Street Military Hospital. 

The right lung was intensely congested throughout, carnified and break- 
ing down easily under the finger or by tearing, at the lower part. Its 
pleura was universally adherent. The bronchial glands were greatly en- 
larged. Left lung healthy. 

The heart was norm.al, containing rather more than the usual amount of 
firm white clot. 

The liver was large and slightly fatty; the spleen quite soft. 

The kidneys were congested ; the supra-renal capsules normal. 

The urinary bladder was very small. Being laid open, its mucous mem- 



106 



Proceedixgs of the 



[July 



brane was found pale and smooth, except at two points, posterior to the 
orifices of the ureters, where there existed deep-red, smooth patches, looking 
like bloodclots. One of these patches was more prominent than the other ; 
the mucous membrane was entire over both of them. 

Feb. 26. Compound Comminuted Fracture of the Skull, and Fracture 
of Bibs. — Dr. Ashhurst presented these specimens, with the following 
history : — 

John S. P. was admitted into the Pennsylvania Hospital, Feb. IT, 1862, 
about 10.30 A. M., on account of an obscure injury received the night pre- 
vious. There were two wounds over the left temple ; one anterior and 
smaller, penetrating to the bone, but not connected with any fracture ; the 
other, about an inch and a quarter long, communicating directly with a 
fracture through both tables of the skull. There was an opening in the 
bone, oval in form, with some fragments lying loose in the wound, which 
were removed by the attending surgeon. An escape of brain substance and 
cerebro-spinal fluid constantly took place from the wound: there was no 
bleeding from the ear, but a piece of lint saturated with blood was found ia 
the pinna, as if bleeding had occurred previous to the patient's entrance into 
the hospital. The patient's mind appeared confused, but active ; there was 
an almost complete loss of language. There was very great dyspnoea, and 
a careful examination revealed a fracture of several ribs on the left side. 

The removal of the loose fragments of bone from the skull was followed 
by some bleeding, which was not, however, so profuse as to be alarming. 

Towards night the patient became worse, and the next morning he pre- 
sented the rather startling symptoms of a pulse of 120 and respiration of 
44 to the minute. Being kept, however, at perfect rest, on absolute diet, 
and with cold applications to the head, with the usual dressing for fractured 
ribs, he improved, and for several days seemed to be in a favourable condi- 
tion. On the morning of the 25th, however, there was a decided change 
for the worse : internal strabismus, at first of the right eye, and afterwards 
of both; dropping of the mouth on the right side; rapid and anxious 
breathing, and a running pulse, all betokened danger : while the hands, 
which lay outside of the bed-coverings, were cold, the skin of the body was 
pungently hot, a thermometer placed in the right axilla indicating a tem- 
perature of 106° Fahr. 

Death, preceded by profound coma, occurred about 1 P. M. of the 26th. 
An autopsy was made three and a half hours after death, with these 
results : — 

Thorax. — Fractures of the third, fourth, fifth, sixth, and seventh ribs on 
left side; extensive old pleuritic adhesions on right side. • One small apo- 
plectic clot on outer edge of left lung. Pneumonia of lower part of right 
lung posteriorly. Ossific deposits on pericardium, and in the heart tissue. 

Head. — Valvular wound in left temporal region, and oval opening in 
skull ; several small pieces of bone imbedded in the dura mater and brain : 
the opening in the skull was about three-quarters by half an inch in dimen- 
sions. There was a clot on either side of the longitudinal sinus. 

The upper surface of the brain, for two inches on either side of the longi- 
tudinal sinus, was covered with lymph ; there was much congestion and 
extravasation under the arachnoid. The tissue of the brain was firm, except 
around and behind the wound, where it was much softened. The wound 
ran through the left anterior lobe of the lirain to the summit of the left 
hemLsphere, and a large clot filled the cavity. 



1862.] Pathological Society of Philadelphia. 107 



In this case death resulted from pressure dependent on hemorrhage, which 
must have been gradual, from the slow approach of the fatal symptoms. 

The medico-legal bearings of this case are of interest. In my examina- 
tion before the coroner's jury I gave the opinion that the injury resulted 
from a fall rather than from a blow, because the fracture in the skull was 
above the wound of the soft parts, not below it ; and I thought most pro- 
bably an upward blow would have glanced and have produced no fracture. 
This view was confirmed by the facts elicited. 

Gangrene of the Lung. — Dr. Leet exhibited a specimen of this lesion, 
the history of which was as follows : — 

Henry B., aged 49, coloured, was admitted February 16, 1862, into the 
Philadelphia Hospital, in charge of Dr. Da Costa. He stated that he had 
been sick for two weeks ; but, owing to his evident stupor, his statements 
about himself were not considered reliable. He affirmed that before the 
onset of the acute attack from which he was suffering, he had had a cough 
from time to time, for the last few years. This was corroborated by the 
nurse, who remembered him in the house, in 1860, with a cough, which 
improved much under treatment. His condition on admission was one of 
extreme prostration ; his breathing very rapid; his pulse quick and feeble; 
his skin hot, and covered with perspiration. His face wore an anxious 
look, and he was evidently not fully conscious. He had spells of coughing, 
after which he expectorated with some difficulty a quantity of dark sputum, 
which in parts was of an olive appearance. Like his breath, it was ex- 
tremely offensive. His weakness was so great that it was with much diffi- 
culty he was propped up in bed long enough to permit of the chest being 
examined. The physical signs detected were marked dulness on percussion 
at the upper portion of the chest, anteriorly and posteriorly on the left side, 
and indistinct blowing respiration, not in the least tubular, and entirely 
unlike that met with in pneumonia. Moist rales could also be heard over 
both lungs. From a consideration of all the circumstances of the case, a 
diagnosis of gangrene of the lung was made. The patient remained until 
the morning of his death much in the same condition as when first seen, 
not responding in the least to the stimulants that were freely administered. 
He became more and more stupid, but still not delirious. For several hours 
before his death the breathing was extremely difficult and very rapid, 
although unattended with pain ; indeed, at no period while under observa- 
tion did he complain of pain, although he always stated when questioned 
that he suffered from a dull feeling of oppression. He died on the 21th. 

At the autopsy a mass of blood, in part clotted, and about a pint in 
quantity, was found in the left pleural cavity. The whole of the upper and 
middle portion of the lung was disorganized, presenting a soft, dirty, and 
broken down appearance, shading off' where the lung became more solid, 
first to a greenish, and then to a grayish hue. The odour from the de- 
stroyed lung was highly offensive, and like that of the breath during life. 
The pleura in the neighbourhood of the disorganized lung tissue had been 
destroyed. The right lung did not show any signs of disease worthy of 
notice. The heart was to the eye healthy. 

March 12. Mammary Carcinoma. — Dr. Ashhurst exhibited a can- 
cerous breast removed by Dr. Pancoast from a patient in the Pennsylvania 
Hospital. 

This patient is a woman forty years of age, who, although married, has 



108 



Proceedings of the 



[July 



never borne cliildren. Her general health is good, except that she suffers 
from haemorrhoids. 

She first noticed this tumour, which was seated in the lower portion of 
the right breast, more than a year ago. It has never given her any pain, 
but during the last few months has increased rapidly in size. She attributes 
this to her having used her arm constantly during this time in sewing. 

The operation was performed under ether. Several of the axillary glands 
being enlarged, were removed. The microscope revealed cancer-cells in the 
tumour itself, but not in the accompanying glands. Since the operation 
this patient's condition has been as favourable as could be desired. 

Rupture of the Urethra. — Dr. Lee exhibited a specimen of this injury, 
and related the history of the case. 

John H., £et. 11, was admitted to the Pennsylvania Hospital March 1, 
1862, with rupture of the urethra and extensive extravasation of urine. 
His mother said that, six months before, he had fallen astride a fence and 
injured his perineum ; he then suffered from retention, but, after some diffi- 
culty, a surgeon passed a catheter, which was retained for several days. 
When this was removed, he could pass a small stream, but his urine soon 
began to dribble, and has continued to do so ever since. In this state he 
remained until the day before his admission into the hospital, when the flow 
of water ceased altogether; his desire to urinate became urgent, and just 
before going to bed he strained violently to pass water but could not suc- 
ceed. In the night, the lower part of the abdomen was swollen and tender; 
he called his mother's attention to it, but she thought nothing of it until the 
next morning, when she found the hypogastrium of a dull purple hue, and 
the penis and scrotum very oedematous and of nearly the same colour. 
About mid-day, she took him to the Jefferson College clinic, where one of 
the clerks recognized his dangerous condition and sent him at once to the 
hospital. When admitted (about 3 o'clock P. M.), he was in a state of 
extreme collapse ; skin cold, and no pulse perceptible at the wrist. The 
scrotum and penis were enormously distended, the former of a dark-brown 
hue; across the hypogastrium and left iliac region there ran a track of 
gangrene three inches broad, of a livid colour, with here and there black 
puffy spots which crepitated under pressure; it was intensely painful to the 
touch, and the little patient tried to relieve the terrible distension by flexing 
the thighs on the body. 

Efforts were at once made by my colleague, Dr. Ashhurst, and myself, to 
introduce a catheter, but without success on account of a tight stricture, 
apparently in the membranous portion of the urethra. I then made free 
incisions in the penis, scrotum, and gangrenous portion of the hypogas- 
trium, from which fluid with a strong urinous odour freely exuded; no in- 
cisions were made in the perineum, as I wished to leave this region free for 
the operation of perineal section, which, had the little patient rallied, would 
have been his only resource. After the incisions were made, yeast poultices 
were applied, and free stimulation constituted the rest of the treatment. At 
first the patient rallied slightly from his collapsed condition, but he speedily 
sank again, and died about 5 o'clock the following morning. 

At the autopsy, the urinous infiltration was found to extend as high as 
the umbilicus, and laterally as far as the crests of the ilia ; thence it de- 
scended to tlie penis and scrotum, which, as already stated, were enormously 
distended. Upon opening the abdomen no urine was found in the pelvis, 



1862.] Pathological Society of Philadelphia. 



1C9 



nor was there any perceptible peritonitis ; it was evident, therefore, that no 
rupture existed posterior to the triangular ligament. 

The bladder and the whole of the urethra were removed together, when 
the former was found much thickened and hypertrophied by chronic inflam- 
mation, and its mucous membrane was streaked with clotted blood. The 
urethra was healthy in the prostatic and membranous portions, but at the 
bottom of the spongy portion a tight impermeable stricture was found, and 
just behind this a gangrenous rent which was plainly the seat of rupture. 
Th'e urine had thus escaped first (as usual in such cases) into the perineum, 
and thence, prevented from reaching the pelvis by the deep perineal fascia, 
it had travelled upwards along the groin into the connective tissue of the 
hypogastrium. Both kidneys were enlarged and sacculated, and the pelvis 
of the left was distended to a marked degree ; that of the right kidney, 
although dilated, was much less so than that of the left. Both ureters 
were also much dilated, but here- the dilatation was chiefly on the right 
side. 

The extravasation of urine had been going on for thirty-six hours, for 
it had evidently begun on the occasion of the straining efl'orts at micturi- 
tion made on the evening before entering the hospital. 

The case was manifestly one of chronic retention with incontinence of 
urine, and, had it not been neglected through the ignorance of the parents, 
could probably have been saved by the same treatment timely applied. 

Dr. Harris remarked that he had searched in vain, in the journals to 
which he had access, for a case similar to this in the gradual formation of 
the stricture. Usually, extravasation of urine took place at once. 

Gunshot Wound of Femur and Pubis. — Dr. Packard read the follow- 
ing account of a post-mortem examination made by him in a case of this 
kind, in a young man, set. 20, wounded at Bull Bun, and subsequently im- 
prisoned for several months in Richmond, Ya. : — 

Autopsy ten hours after death. — Wound only examined. Body excessively 
emaciated; legs and feet oedematous. Yery little, if any, rigor mortis. 

The orifice of entrance of the ball, completely cicatrized, was observed 
near the upper edge of the left trochanter major. The opening by which 
it had been removed, in the fold between the perineum and left thigh, about 
opposite the posterior boundary of the scrotum, gave exit to bloody, ill- 
conditioned pus, whenever pressure was made upon the surrounding parts. 
From this latter opening there led olf several sinuses, lined with black 
sloughy matter. 

On dividing the integuments towards the back of the thigh on a director, 
and thus laying open one of these sinuses, the trochanter minor, detached, 
was found, as well as the inner wall of the upper end of the shaft, burst 
out, as it were, into several fragments. The shaft of the femur seemed 
swollen and rough ; but a closer examination showed that this was a shell 
of new bone, inclosing the necrosed upper two-thirds of the true shaft. At 
one part of the anterior face of this shell was an irregular opening, about 
an inch wide by an inch and a half long, closed by a blackish, sloughy, but 
tough fibrous expansion. Perhaps an explanation of the necrosis may be 
found in the fact that several small splinters of bone had been driven down 
along the medullary canal, and may have wounded the nutritious artery. 
A clot occupied the canal, very dark-red and tough above, paler and softer 
below. In the upper part of the cavity of the shell of new bone, there 
existed several necrosed and decomposing fragments. 



110 



Proceedings of the 



[July 



The hip-joint, when laid open, was found to contain some turbid reddish 
synovia, and the foveola of the acetabulum was reddened and evidently un- 
sound. None of the surrounding abscesses, however, had formed any con- 
nection with the joint. 

The ball seemed to have struck the ischium between the tuberosity and 
the spine, and to have passed up along the ramus nearly to the crest of the 
pubis, gouging away the anterior or outer wall of the medullary cavity of 
the rami. 

A sloughy sinus or abscess extended down the inner side of the thigh as 
far as the knee, and others were traced up under Poupart's ligament as far 
as the origin of the psoag muscles. 

If, as was stated, this injury was inflicted by a Minie ball (and hardly 
any other would have produced such havoc), the course taken by the pro- 
jectile was different from that which has been observed in most other cases. 
The ball would seem to have entered over the trochanter major, passed 
backwards and inwards, through the broad cancellous upper extremity of 
the shaft of the femur ; after breaking through the inner wall of the latter, 
it passed across to the border of the pelvis, and ploughed its vi^ay upward 
till its force was spent. For a round ball to have thus rolled irregularly 
about would have been no very strange matter ; but we have been given to 
understand that the Minie ball forced its way without deviation. 

Another point is well illustrated by this case, namely, that longitudinal 
splitting seldom, if ever, crosses the line of junction of an epiphysis. Here 
the shattering of the bone was very severe, and yet above the line just 
referred to, there was not even a fissure — a fact which accords with the ex- 
perience of Stromeyer and Macleod. 

3Iarch 26. Deformity of Legs. — Dr. Lee exhibited the bones of a leg 
amputated for deformity, and a cast of the limb before removal, with the 
following history of the case : — 

Sanford A., aet. 19, from Ohio, was admitted to the Pennsylvania Hos- 
pital March 13, 1862. From infancy, he had suffered from fragilitas ossium, 
and the lower limbs had been repeatedly fractured; his right leg alone had 
been broken ten or twelve times. After these accidents the bones would 
very rapidly unite, so that in two or three weeks he was able to go out 
again. That firm union was gained so soon could not be established, be- 
cause he never walked upright, but always upon his knees, dragging the feet 
after him. This had always been his gait, and by this means he constantly 
excoriated the shins, which scraped along the ground as he walked; for, 
from some unknown cause — perhaps from tight splintering after his nu- 
merous fractures — both tibiae had become so bent forward as to leave a sharp 
and very prominent angle about the middle of the bones. This portion of 
the leg was protected by a leather casing, but, in spite of it, was kept con- 
stantly sore from pressure as the patient walked. 

In the left leg the deformity was much the greater, and, as it was also 
the weaker of the two. Dr. Pancoast determined to remove it, and substi- 
tute an artificial leg, by which he hoped to enable the patient to walk erect. 
The amputation was done by double skin flaps, and, with the exception of 
some necrosis of the tibia, the patient progressed well. Upon dissection, 
the tibia was found of normal size, but flattened and bent to a wonderful 
degree and rather softer than usual; while the fibula, quite translucent and 
almost as thin as paper, was displaced behind the tibia, so as to be in an 



1862.] Pathological Society of Philadelphia. Ill 



exact line with it antero-posteriorly. The bones of the foot were remark- 
ably attenuated, but the limb was otherwise normal in structure. 

in the other regions of the body there was no special deformity, except 
the fingers of the left hand, which were rigidly contracted as if by chronic 
arthritis. But the point of special interest about the case was the apparent 
paradox of coexistent mollities and fragilitas ossium ; the bones of the leg 
w^ere sufiSciently fragile to break frequently from the most trivial causes, 
and yet so soft as to be moulded completely out of shape by the mere ap- 
plication of splints — the patient's testimony on this point being confirmed 
by that of his former surgical attendants. 

Incarcerated Hernia. — Dr. Lee showed this specimen, the history of 
which was as follows : — ■ 

Andrew Wilson, between TO and 80 years old, was admitted to the Penn- 
sylvania Hospital March 14, 1862. For several years he had had double 
inguinal hernia, the tumour on the left side being larger than that on the 
right ; and although he wore a double truss, it occasionally slipped down 
into the scrotum, but was easily returned. On the day before his admission, 
however, the hernia had come down and he could not reduce it. No pain 
or inflammation followed, but he became alarmed and came to the hospital 
for treatment. When admitted he was apparently in good condition for so 
old a man ; no prostration, nausea, &c. ; and the scrotal tumour, though 
exceedingly tense and hard, showed no evidence of strangulation. Nothing, 
therefore, was done immediately; but after a few hours' rest he was given 
a warm bath, and was afterwards thoroughly etherized by Dr. Ashhurst, 
who made careful and long-continued efforts at reduction without any effect. 
I understood from Dr. Ashhurst that he was under the influence of ether 
fully an hour. After this he was subjected to no further treatment until 
the following morning, w^hen the attending surgeon (Dr. Paucoast) arrived. 
He was now again etherized, and a second prolonged but fruitless manipu- 
lation was made by the attending surgeon and one of his colleagues. 

Although the hernia was incarcerated only, it w^as plainly irreducible, 
and from the obstinate constipation, wdiich had existed several days, the 
danger of strangulation was imminent. The constriction existed at the 
external ring alone, and Dr. Pancoast therefore resolved to perform an 
operation which he had practised with perfect success in seven or eight 
similar cases, and which he thinks was originally practised by himself, 
although the suggestion is due to M. Guerin, of Paris. This consists in 
puncturing the skin over the tumour, introducing a grooved director which 
is pushed up subcutaneously to the external ring, and there insinuated under 
the fibres of the aponeurosis of the external oblique muscle, which forms 
the constriction. The position of the director being now carefully ascer- 
tained through the skin, a second puncture is made with a curved bistoury 
just below the raised bands of tendon, and the fibres carefully divided by 
rocking the handle of the knife. In other words, the operation is one of 
subcutaneous tenotomy. After this procedure w^as adopted, the hernia was 
with a little difficulty completely restored to the abdomen ; a portion of the 
tumour, by the way in which it returned, was clearly ascertained to be bowel. 
A compress and spica bandage being applied, the patient was put to bed, 
and after he had recovered from the effects of the ether a large opening 
injection was given. This acted but slightly, and during the afternoon, 
from the restlessness of the patient or the carelessness of the assistants, 
the hernia came down again. 



112 Proceedings of the [July 

As soon as I discovered this I removed the bandag:e and did my best to 
replace the tumour, but without success. Some pain was caused by the 
manipulation, on which account the patient was given an opiate and kept 
perfectly quiet. The following morning a fresh attempt was made at 
reduction by Dr. Pancoast, and failing in this, he ordered the patient to be 
etherized for the third time. When fully under the anassthetic, another 
more patient and steady effort was made to replace the tumour, but with 
no better success. Dr. Pancoast was now convinced that some undivided 
bands of fibres formed the obstacle to reduction; he therefore carefully 
repeated the operation of the previous day. The hernia was now returned 
with perfect ease, and was retained in place more securely than before. 
Dr. Pancoast remarked at the time that the more solid portion of the 
tumour was hardened omentum. The patient recovered rather slowly from 
the ether, was ordered a grain of opium every four hours, and that day and 
the following night he did well. The next morning I noticed some difiB- 
culty of respiration, with blueness about the face and nails. Auscultation 
revealed marked pulmonary congestion and oedema. The opium was at 
once stopped, and free stimulation, both internal and external, was substi- 
tuted. Still the patient continued to sink, and died of suffocation about 
mid-day. The belly was a little tympanitic, but no decided symptoms of 
peritonitis existed. 

At the autopsy the lungs were found completely gorged with serous 
effusion, with here and there a patch of pulmonary apoplexy and much 
diffused congestion; on the left side were old adhesions, while nearly a pint 
of serum Avas found in the right pleural cavity. The heart was normal in 
consistence, but both auricles and ventricles were filled with fluid blood; in 
the left ventricle was a small fibrinous coagulum, and a few "currant-jelly" 
clots, but they were extremely soft and diffluent. On laying open the her- 
nial tumour, a little clotted blood was found in the subcutaneous tissue, and 
the sac, indurated and thickened, was completely adherent to the tunica 
vaginalis and to the cord. Its internal surface exhibited intense venous 
congestion, apparently chronic; this extended about an inch above the ring 
along the peritoneal coat, but no further; there was not the slightest ap- 
pearance of general peritonitis, nor was the local inflammation of a very 
high grade. 

The neighbouring intestines were quite healthy, but on opening the ab- 
domen the cause of all the trouble was at once seen in a mass of omentum 
about three inches in every diameter, intensely inflamed, and so indurated 
as to resemble a piece of India-rubber; from this mass the congested omen- 
tal vessels spread over the surface of the omentum, gradually lessening in 
intensity. The other abdominal organs were healthy. 

Compound Comminuted Fracture of Thigh; Fracture of Scapula and 
of Bibs, ivith hcalp Wounds and Effusion on Brain. — This specimen was 
presented by Dr. Ashhurst. 

Daniel McA , aged 49 5^ears, was admitted into the Pennsylvania 

Hospital on the 22d of March, 1862, having been injured by being caught 
in the belting of some machinery. The shock was ver^ considerable, but 
he did not appear to have lost much blood. 

His left thigh was found to have been fractured in its middle third, and 
a small wound on the back of the limb communicated with the bone. The 
main arteries of the thigh were uninjured. 

The head of the humerus of the same side appeared to be prominent, and 



1862.] Pathological Society of Philadelphia. 113 



almost gave the appearance of an anterior luxation, but upon closer exami- 
nation it was evident that the injury was a fracture of the acromial process 
of the scapula, which had fallen iDackwards bv its own weight. There were 
several small scalp wounds on the left side penetrating to the bone, which, 
however, appeared uninjured. There was marked orbital ecchymosis of the 
left side which o-ave rise to suspicion of the existence of a fracture of the 
skull. 

Under stimulation the patient reacted well, but towards evening he began 
to sink again. At 1 A. M. his pulse was so rapid that it could not be 
counted, aud his respirations 40 to the minute. He henceforth became 
weaker aud weaker, and, finally, died about 4i P. M. the next day. 

An autopsy was made five hours after death. 

On the head there were several small scalp wounds. Some effusion of 
blood under the pericranium, but no fracture whatever of the skull. Blood 
was efi'used on either side of the longitudinal sinus on the summit of the 
middle lobes of the cerebrum, especially on the right side. There was. also, 
a small clot on the extreme posterior part of the left side at the base of the 
brain. Between the membranes and upon the surface of the brain there 
were about f5iij of bloody serum. The brain matter itself appeared healthy. 

On the left side the acromial process of the scapula was obliquely broken 
off and a ragged fracture existed in the infra-spinous fossa. The muscles 
of the shoulder were infiltrated with blood. 

The first rib on the left side was broken near its sternal end, the fourth 
far back. The lungs and heart were healthy; the ventricles contained some 
small currant jelly-like clots. 

The liver was slightly fatty ; the other abdominal organs healthy. 

The thigh presented a comminuted fracttire, the bone being splintered as 
high as its upper third. The muscles were much lacerated, and some com- 
pletely torn from their own sheaths. 

Death had resulted from the effusion on brain. 

April 9. Compound Fracture of Sacrum. Exhibited by Dr. Lee. 

John McC , set. 45, was admitted to the Pennsylvania Hospital, 

April 5, 1862, having an hour before fallen a distance of forty feet from a 
scaffolding, sustaining numerous injuries. He had well-marked fractures 
of the lower third of the left radius, of both bones of the right leg, and of 
four or five ribs on each side. There was also a compound fracture of the 
sacrum. When admitted the right lower extremity was everted and short- 
ened so as to lead to a suspicion of a fracture of the thigh. This error was 
at once recognized, aud while examining the pelvis a punctured wound was 
observed over the sacrum; the finger introduced into this detected a frac- 
ture' running transversely across the sacrum with very marked depression of 
the lower third of the sacrum and the coccyx. These fragments were 
jammed tightly against the rectum, which, however, was not lacerated; 
reduction was efiected by means of the finger in the rectum, and required 
considerable force. The patient never rallied from the primary shock, and 
died in six hours. At the autopsy the sacrum was found comminuted, a 
large fragment of the left ala being broken off longitudinally and disphiccd 
to a considerable extent. The sixth, seventh, and eighth ribs on the right 
side, besides being broken in several places, were torn from their sternal 
attachment, the irregular lacerations in the cartilage being plainly visible. 
Althouo-h onlv six hours had elapsed since the accident pleuritis had already 
^'o. LXXXYIL— July 1862. S 



114 



Proceedings of the 



commenced, the costal pleura on both sides being dry, rough, and intensely 
injected. Contrary to expectation no lesions of the internal viscera were 
found. 

April 23. Compound Comminuted Fracture of Skull; Fracture of 
Pelvis and Bupture of Bladder. — Dr. Lee showed these specimens with 
the following history : — 

Wm. Shoemaker, «t. 54, was admitted into the Pennsylyania Hospital, 
in a comatose condition, at 5.30 A. M., on April 13, 1862. His friends 
stated that he had fallen during the night from a second .story window, at 
what exact time they could not tell, for he was only found at 5 o'clock in 
the morning. His respiration w^as stertorous and blowing, and partial 
paralysis of the right side existed; the left orbit was densely ecchymosed. 
On examining the head a punctured wound was found near the top of the 
left parietal bone, through which distinct fracture with depression could be 
felt. The line of fracture seemed to extend into the frontal bone and then 
across the right side, but as the man was evidently moribund no elfort to 
raise the depressed bone and no further examination was made. Both ears 
were so bloody that no hemorrhage or serous discharge could be made out 
with certainty. He died within two hours. 

Aidopsy seven hours after death. — On removing the scalp there was 
found a large effusion of blood and a most extensive comminuted fracture 
involving the frontal and both parietal bones, extending into the left orbit 
and passing through the left zygomatic arch into the temporal bone. When 
the calvaria was taken off no clot was found under the membranes at the 
seat of fracture; the membranes, however, were much lacerated, and a large 
submeningeal coagulum was seen at the base of the brain completely cover- 
ing in the crura cerebri, and the pons ; there was, however, no fracture 
whatever of the base. Before opening the abdomen a little blood was seen 
trickling from the penis, and on examination a comminuted fracture of the 
pelvis was discovered. This seemed to begin at the posterior part of the 
left ilium, running forward to the acetabulum, where the head of the femur 
w^as also indented, and, finally, involving both the ischium aud the spine of 
the pubis. The jagged fragments of the latter bone had made tw^o very 
large lacerations in the bladder, which w^as collapsed and lying loosely at 
the bottom of the pelvis ; but the urethra had escaped injury. In the pelvis 
was effused a large quantity of bloody urine which had begun to infiltrate 
the connective tissue of the scrotum and hypogastrium. There also existed 
fracture of four or five ribs, but the thoracic and abdominal viscera were 
healthy. 

Ruptured Peritoneum. — Dr. Ashhurst read the following account of a 
case of this injury: — 

Patrick C was admitted to the surgical ward of the Pennsylvania 

Hospital on the 24th of last December, about 8 P. M. His injuries ap- 
peared to be but slight. He had been struck by the cow-catcher of a loco- 
motive on the Norristown Railroad, and presented a contused wound of the 
brow and slight scratches on both legs. He was excessively drunk and 
.troublesome. During the night he became so restless and even violent that 
it was necessary to secure him in bed by means of mechanical restraint. 
He now began to complain of great pain in the epigastric region. 

The next morning he was sober, and evidently very dangerously ill; his 
brci).thing was very difficult, and accomplished entirely by the diaphragm. 



1862.] Pathological SociETir or Philadelphia. 115 



the abdominal muscles being kept as motionless as possible. He was very 
restless, tossing from side to side, occasionally vomiting a liquid of a dirty 
green colour, constantly complaining of excruciating pain in the abdomen, 
and exclaiming that he was going to die. 

This state of things lasted through the morning without much change. 
On going to his ward about 3 o'clock on Christmas afternoon, I found him 
lying on the floor with his face downwards, having immediately before 
thrown himself out of bed. He was at once taken up, but expired within 
a few minutes. 

An autopsy was made fifteen and a half hours after death, with the fol- 
lowing results: — 

Abdomen. — There was found very extensive peritonitis, with recent effu- 
sion of lymph. Large clots were found in the omenta, especially the gas- 
tro-colic. The left kidney was enlarged and much congested, and contained 
several well-marked clots. The liver was slightly fatty. 

The lungs were slightly congested, the congestion being hypostatic. 

All the other organs examined appeared to be healthy. 

This I believe to have been one of those rare cases of rupture of the 
peritoneum without rupture of the viscera; for the left kidney, althougli 
badly bruised, as shown by the clots found in its substance, did not appear 
to have been ruptured. 

Mr. Pollock, in his paper on Injuries of the Abdomen, in Holmes'' Sys- 
tem of Surgery, considers that the first and most serious danger in ruptured 
peritoneum is from hemorrhage: this is apt to be profuse if the part injured 
be the omentum or mesentery, or if, as sometimes happens, the laceration 
be in the peritoneum covering the pregnant uterus. If, on the other hand, 
it be the parietal portion which is injured, the hemorrhage will be slight, 
and the risks of inflammation are principally to be feared. The course of 
traumatic peritonitis is very rapid : Erichsen refers to a case of gunshot 
wound in which death ensued after twenty-four hours: there was much 
serous effusion and puro-plastic matter exuded. In my case, though death 
ensued only nineteen hours after admission, the appearances of inflammation 
were well marked. 

I have seen several cases of injury to the abdomen which at first caused 
more alarm than this one, and yet which proved entirely without danger. 
In one, especially, the man was squeezed between the bumpers of two heavy 
cars, and when brought into the hospital was, in his own opinion as well as 
in that of his friends, in a dying condition. Kest for a few days, with 
sedative and anodyne fomentations, restored him to health. 

May 1 4. Comminuted Fracture of Pelvis, Fracture of Thigh, &c.. 
Exhibited by Dr. Lee. 

John F., set. 46, was admitted into the Pennsylvania Hospital April \ 2th, 
1862. A brick wall, suddenly thrown down by some other workmen, had 
buried him in the ruins. When brought to the hospital, his right thigh was 
found broken in the upper third; the left fibula was also fractured, and a 
lacerated scalp wound extended nearly half way around the right side of the 
head. As some perineal ecchymosis was observed, a catheter was at once 
introduced, but only after considerable difficulty, a firm obstruction occurring 
behind the bulb, as if something was closely compressing the canal. Every 
time a catheter was introduced the same feeling of resistance was encoun- 
tered, but at the time this was attributed to the large effusion of blood in 
the perineum. A careful examination made of the pelvis and other parts 



116 



Proceedings of the 



[July 



revealed no further lesion, and the man was at once put under treatment 
for his fractures. For a fortnight he seemed to improve, but then became 
much worse, with frequent rigors, prostration, and generally typhoid con- 
dition. In this state he lingered a week longer, and then died apparently 
of sh6er debility. At the autopsy, made eight hours after death,- my sur- 
prise was great to find a thoroughly comminuted fracture of the horizontal 
and descending rami of the pubis; a small fragment was driven through 
the perineal structures and lodged immediately underneath the urethra, 
behind the bulb ; this it was that had formed the obstacle to the introduc- 
tion of the catheter, the urethra itself being intact, and the perineal effusion 
caused by the loose fragment. The peritoneum was injected and discolored 
of a brownish-green hue, with here and there patches of lymph still adhering. 
There was very little effusion into the viscera, all looked healthy. Along 
the periosteum covering the ends of the broken fragments of the thigh the 
soft callus was seen deposited in small quantities, but nothing like an 
attempt at firm union had taken place. 

Dr. AsHHURST called the attention of the Society to two cases of 
abscesses of the kidney. 

1. Tubercle of Kidney. The diseased organ, preserved in spirits, was 
exhibited in connection with this account. 

Martin C . a sailor, aged thirty-two years, was admitted into the 

Pennsylvania Hospital for gonorrhoea, followed by stricture and fistula in 
perineo, the fistula opening in the perineal centre. The urethra was much 
implicated ; irritation of both bladder and kidneys was manifested ; the 
urine became loaded with pus, its reaction being acid and at no time am- 
raoniacal. Death took place from colliquative diarrhoea of a few days' 
duration, on the 11th of July, 1861, nearly eighteen months subsequent to 
his entrance into the hospital. An autopsy made the next day revealed the 
following state of things : The body was greatly emaciated, and decompo- 
sition had already begun. Pleuritic adhesions existed on both sides of the 
thorax. The left lung contained disseminated tubercle in various stages of 
degeneration, with, however, no cavities. In the right lung the deposits 
of infiltrated tubercle were yet more numerous. 

The liver was yellow and fatty in appearance. The intestinal glands 
were congested, but not enlarged. The left kidney was somewhat enlarged, 
pale and fatty in appearance, and with the tubuli and cortical portion 
blended so that it could hardly be said where the one ended and the other 
began. The right kidney was of enormous size, and contained abscesses in 
all parts, varying in magnitude from the size of a pea up to that of a 
walnut. Some hardened masses, small in size and slightly softened in the 
interior, seemed to indicate a tuberculous nature. But little kidney struc- 
ture remained. The ureter much thickened, and presenting pus in its 
course to the bladder, which afforded those evidences of chronic inflamma- 
tion which were naturally expected. 

That the abscesses in this kidney were of a tuberculous nature, may be 
regarded as probable, from the fact that tubercle was found so extensively 
in the lungs. 

There are, according to Rokitansky, two distinct forms of renal tubercle. 
The first is merely a symptom of a "very high degree of tubercular dys- 
crasia,"-by which many or most of the viscera, especially those of the abdo- 
men, are affected, and by Avhich both kidneys are generally uniformly 
attacked, while suppuration rarely if ever ensues. 



1862.] Pathological Society of Philadelphia. IIT 



The second form is limited to the genito-nrinary apparatus ; though it 
frequently ensues upon a tuberculous state of the lungs, while on the other 
hand pulmonary tuberculosis not unfrequently follows upon the advanced 
stages of this kind of renal tubercle. This form generally commences in 
the testes and the lymphatic glands therewith connected, and is often 
spoken of as gonorrhoeal tubercle, though no difference has been perceived 
between the deposits in this and other forms of tubercle. One kidney alone 
is attacked in this form, and great renal enlargement, suppuration and the 
formation of abscesses of considerable size are among its characteristics. 

In this class the case reported would seem to find its place, and it may 
be regretted that no examination of the testes was made, as had evidence 
of tuberculous deposit been found there, comparative certainty would have 
been attained. 

Whether the gonorrhoea, for which this patient was first admitted, had 
any direct connection with the deposit of tubercle, may be doubted. If it 
had, and such a connection could be shown to exist, the name of gonor- 
rhoea! tubercle would not be so inappropriate as Rokitansky seems to 
consider it. 

2. The form of inflammation which in the kidney most frequently termi- 
nates in suppuration is chronic, and arises from calculous irritation of the 
pelvis. Of this condition the following case is an illustration : — 

Augustus L , a seaman, twenty-four years old, died on the 3d of 

August, 1861, with the condition of kidneys and bladder to be described 
below. 

He was admitted into the Pennsylvania Hospital for stricture of the 
urethra and incontinence of urine ; electricity was applied to the neck of 
the bladder without benefit. Bougies were passed and injections of lauda- 
num and flaxseed mucilage into the bladder were employed without any 
good result. About a week before death symptoms of acute cystitis were 
developed, and the patient soon fell into a state of extreme prostration 
with cold, clammy skin, running pulse, and ghastly countenance, all of 
which symptoms persisted until the fatal issue. An autopsy was made 
thirteen and a half hours after death, with these results : The omentum 
was adherent to the abdominal parietes. The bladder was very much 
ribbed and inflamed, and to its mucous surface pus and phosphates were 
adherent. The kidneys were much enlarged, containing abscesses and 
deposits of phosphates ; the ureters, however, were not afi'ected. 

The disease in this case began, no doubt, in the kidney. That inflam- 
mation beginning in the bladder should cause nephritis, without involving 
the ureters, we can hardly suppose, but pus and even phosphatic formations 
might pass downwards from the kidney and thus produce cystitis without 
giving rise to any marked changes in the ureters during their course. 

These two autopsies occurring within a short time of each other, the 
patients having been admitted for the same affection (in each case stricture 
resulting from gonorrhoea), and the post-mortem appearances while pre- 
senting at first sight points in common, yet illustrating really far different 
conditions, all these considerations have induced me to present the cases 
together to the Society, as suitably accompanying each other, and illus- 
trating some rather obscure points in renal pathology. 

Metastatic Abscesses. — Dr. Packard gave the following account of an 
autopsy in a case of so-called pi/f^mia at St. Joseph's Hospital. The 
patient w^as a soldier, ast. 25, who had been shot in the right thigh, at 



118 



Pathological Society of Philadelphia. 



[July 



Winchester, five weeks previous to his death. Dr. Hunt, under whose care 
he had been, made the dissection. 

The wound, which was at the upper and inner part of the right thigh close 
to the vessels, was first examined. An injection of solution of chloride of 
zinc had been made into the artery, which vessel, as well as the vein, was per- 
fectly sound. On enlarging the wound and reflecting back the skin, rectus, 
sartorius, tensor vaginae femoris, and outer head of the vastus, the ball, a 
large, round, leaden one, was found lying in an intermuscular space ; it had 
been flattened out by striking the bone. The neighbouring muscular tissue 
was in a state of fatty degeneration. On the anterior surface of the bone, 
about an inch below the level of the lesser trochanter, was a depressed por- 
tion, not involving the entire thickness of the wall of the bone, and having 
on it a black spot which seemed to indicate the point where the ball struck. 

The femoral vein was perfectly sound and healthy, as were also the iliacs 
and the ascending cava. In the liver an abscess existed at the upper and 
back part of the right lobe ; the organ itself was fatty, but the veins of both 
systems were healthy. The pus contained in this abscess was thick and 
clotty, but of a bright yellow colour; its ill-defined walls were composed of 
softened gland tissue. 

Abscesses were found at the posterior portions of both lungs, especially 
of the left; the lung tissue in the vicinity of these abscesses did not seem to 
be indurated, and there was no pleurisy apparent. 

The heart was of normal size, with rather more yellow fat upon it than 
is usually seen in persons only twenty-five years of age; it was full of firm 
yellow clots. All the other organs seemed healthy. 

This case would seem of itself sufficient to overthrow the idea that metas- 
tatic abscesses are due to an arrest in the bloodvessels of the viscera of pus- 
cells derived from an inflammation of the veins at some point. It is simply 
presented as an additional item of negative evidence. 

Deficiency in the number of Bibs. — Dr. Packard mentioned that at an 
autopsy made by Dr. S. W. Mitchell, at which he was present, it was found 
that the subject of the examination had only eleven ribs on each side. The 
fourth rib on the left side was broad anteriorly, and joined the sternum by 
a broad cartilage, perforated, as if to indicate its normally double state, by 
a round hole. On the right side there was simply a broadening of the 
anterior end of the fourth rib. 

The case was one of rapid phthisis in a woman thirty-nine years of age. 



1S62.] 



119 



REVIEWS. 

Art. XII. — Theories of Life and Organization. 

1. Becherches Fhysiologiques sur la Vie et la Mort. Par F. X. Bichat. 
Nouvelle edition, precedee d'une Xotice sur la vie et les Travaux de Bichat 
et suiYie de Notes par le Docteur Cerise. Paris : Victor Masson et Fils, 
1862. 8vo. pp. 382. 

2. De la Vie et de V Intelligence. Par P. Flourens, Membre de PAca- 
demie Francaise et Secretaire perpetuel de P Academic des Sciences (In- 
stitut de France), etc. Paris: Grarnier Freres, 1858. 8vo. pp. 161. 

3. La Medecine Nouvelle basee sur des Principes de Physique et de 
Chimie transcendanfes et sur des Ea'periencea copitales qui font 
voir mecaniquement Vorigine du Principe de la Vie, Par L. Lucas. 
Paris: F. Savy, 1861. Tome ler. 8vo. pp. 504. 

4. La Vie dans V Homme; Existence, Fonction, Nature, Condition pre- 
sente, Forme, Origine et Deatinee future du Principe de la Vie; 
Esquisse Historique de V Animisme. Par J. Tissot. Paris : Victor 
Masson et Fils, 1861. 8vo. 

5. La Vie dans V Homme ; ses Manifestations diverses, leurs Rapports, 
lews Conditions Organiques. Par J. Tissot. Paris : V. Masson et 
Fils, 1861. 8vo. pp! 614- 

6. Discours sur le Vitalisme et V Organicisrae et sur les Bapports des 
Sciences Physiques en General avec la Jledecine: Discours prononce a 
P Academic Im|3eriale de Medecine, 17 Jaillet, 1860. Par M. le Pro- 
fesseur BouiLLAUD- Paris: 1860, 8vo. pp. 75. 

Life-actions, their origin and cause, are still vexed questions in medical 
philosophy. Notwithstanding the steady progress of the ars et scientia 
medendi, during the past twenty centuries, we are compelled to admit that 
the definitions and theories of life are as unsatisfactory as they are numerous 
and varied. Than the existence of these theories no greater proof could 
be adduced of the inherent difficulties attendant upon all investigations into 
the cause of vital phenomena — dif&culties increased tenfold by the confusion 
which is inseparable from such studies when pursued in accordance with the 
metaphysical method. 

Never, perhaps, will we be able to assign to physiology its appropriate 
place among the sciences, until the great problem of life is either solved 
or reduced to a determinate and intelligible formula. The scientific status 
of medicine must be determined by the position and progress of physio- 
logy, which is far from being an exact science. Consisting of numerous 
isolated groups of facts, whose relations are by no means understood, 
it is at the present moment in the same condition as was the science 
of physics anterior to the time of Newton, or that of chemistry before the 
era of Lavoisier. The discovery and announcement by Newton of the 
gravitating law of matter, and the universality of its application, were 
snfncient to stamp all the phenomena of physical science — many of them 
up to that time inexplicable — with the authoritative seal of precision and 



120 



Reviews. 



[July 



exactitude. So, also, the discovery of the law of chemical affinity by 
Lavoisier did much to deprive chemistry of its purely experimental and 
uncertain character, and place it upon an exact philosophical basis. Com- 
parative anatomy and palasontology were for a long time mere collections 
of details of vague import, until Cuvier proclaimed the important law of the 
correlation of forms. And now profound thinkers in our profession are 
thoughtfully awaiting the advent of some medical Newton, who, with dis- 
criminating mind, shall separate the true from the ''false" facts of medi- 
cine, and, with enlarged conceptions of the conditions of life, seize upon 
and demonstrate that great primitive fact or principle which is peculiar to 
and underlies and co-ordinates all the phenomena of medicine. 

It is a remarkable fact that, in tracing the history of speculation upon 
the source of vital phenomena, the more we approximate the commence- 
ment of the historical period, the more simple and positive do we find to 
be the notions of life. In the history of philosophy no feature is more 
remarkable than the pertinacity with which the ancients maintained the 
existence of an independent principle or force as the primary and efficient 
cause of motion and life throughout the universe. This was' essentially 
the doctrine of Thales, the founder of the Ionian school, of Parmenides, 
Archelaus, Heraelitiis, Deraocritus, Pythagoras, Hippocrates, Plato, and 
Aristotle. The Stoics, according to Cicero, held the same opinion. Long 
anterior to the time of the Greeks, we can trace it among the Hindoos^ 
Persians, and Egyptians. It appears to have been a fundamental dogma 
in the Chaldean, Phoenician, and other ancient theogonies, and was for ages 
inculcated in China by Confucius and his disciples. 

After the decadence of Grecian and Roman civilization, and the estab- 
lishment of Christianity, the ruling doctrine of the ancients concerning the 
cause of vitality appears to have been forgotten, or altogether subverted 
and replaced with the most wild and fanciful notions, which, under various 
forms, continued to prevail and find advocates throughout that long and 
dreary period familiar to the historian as the Dark Ages. 

To become acquainted with the views upon this subject entertained in 
the latter part of the sixteenth and early portion of the seventeenth centuries, 
we have only to look into Harvey's work. Be Generatione Animalium, 
published in 1651. In this work are embodied the notions of the illus- 
trious English physiologist relative to the vital principle, life and organiza- 
tion. These notions are confused, conflicting, and unsatisfactory, if not, 
indeed, unintelligible. In the 71st exercise he tells us that — 

" There is a spirit or certain force, inherent in the blood, acting superiorly to 
the powers of the elements, very conspicuously displayed in the nutrition and 
preservation of the several parts of the animal body; and the nature, yea, the 
soul in this spirit and blood is identical with the essence of the stars." 

This " spirit," he expressly says, is identical with the impetiim faciens 
or moving power of Hippocrates. In another place he asserts that the 
blood itself, by reason of its admirable properties and powers, is "spirit" 
— that it is the only calidum innatum, or firi>t engendered heat, and the 
immediate and competent instrument of life. He quotes Suidas to the 
effect that the blood is the living principle of man, and adds that this is 
true of all animals. He combats and ridicules the views of Scaliger and 
Eernelius, who believed in the existence of a spirit different from the in- 
generate heat, of celestial origin and nature — a subtle aura filling the 
arteries, sinuses of the heart, and ventricles of the brain, and cherished or 



1862.] 



Tlieories of Life and Organization. 



121 



renewed by the act of inspiration, and, being of extreme lightness, vanishes 
insensibly upon the death of the animal. 

*' What occasion is there," he asks, " for this extraneous inmate, for this 
ethereal heat, when the blood is competent to perform all the offices ascribed 
to it, and the spirits cannot separate from the blood even by a hair's breadth 
without destruction ; without the blood, indeed, the spirits can neither move 
nor penetrate anywhere as distinct and independent matters." 

One hundred and thirty-five years after the utterance of this language, 
the celebrated John Hunter, in his Lectures on the Principles of Surgery 
and his Treatise on the Blood, Ivjlammation, and Gunshot Wounds, gave 
to the world his opinions upon the vital principle and the connection exist- 
ing between life and organization. These opinions are worthy of examina- 
tion, inasmuch as they represent very fairly the condition of the question 
at the close of the eighteenth century. 

" Animal and vegetable substances," says Hunter in his Lectures delivered in 
1786-7, "differ from common matter in having a power superadded, totally 
different from any other known property of matter, out of which arise various 
new properties. * * * * -^^ Unless we consider life as the immediate cause of all 
actions occurring either in animals or vegetables, we can have no just concep- 
tion of either vegetable or animal matter. * ^ ^ In treating of an animal 
body I shall always consider its operations, or the causes of all its effects, as 
arising from the principle of life, and lay it down as a rule that no chemical or 
mechanical property can become the first cause of any of the effects in the 
machine. * * -h- 'yi-^q living principle, in itself, is not in the least mechanical, 
neither does it arise from, nor is it in the least counected with any mechanical 
principle. * * * Although life may appear very compounded in its effects in 
a complicated animal like man, it is as simple in him as in the most simple 
animal, and is reducible to one simple property in every animal. * ^- ^ ^ The 
principle called life cannot arise from the peculiar modification of matter, be- 
cause the same modification exists where this principle is no more." 

So in his Treatise on the Blood, published in It 93, he writes: — 

" I shall endeavour to show, that organization and life do not depend in the 
least on each other ; that organization may arise out of living parts, and pro- 
duce action : but that life never can arise out of, or depend on organization, * 
-X- ^ Mere organization can do nothing even in mechanics; it must still have 
something corresponding to a living principle, namely, some power. I had long 
suspected (from about the year 1755 or 1756) that the principle of life was not 
wholly confined to animals, or animal substances endowed with visible organi- 
zation and spontaneous motion ; I conceived that the same principle existed in 
animal substances devoid of apparent organization and motion, where there 
existed simply the power of preservation." 

In his Lectures on the Principles of Surgery, he tells us that — 

"The living principle is the immediate cause of action in every part: it is 
therefore essential to every part, and is as much the property of it as gravity is 
of every particle of matter composing the whole. Every individual particle of 
the animal matter, then, is possessed of life, and the least imaginable part which 
we can separate is as much alive as the whole." 

He acknowledges that "the simple principle of life can with difficulty 
])e conceived," and proceeds to state that "the first and most simple idea 
of life, is its being the principle of self-preservation, preventing matter 
from falling into dissolution ; and the second is its being the principle of 
action." In another place he says that "life is not action," and in still 
another, that it is " the susceptibility to impression, with a consequent 
power of action." 



122 



Keviews. 



[July 



Erom these quotations from his writings, it is very evident that Hunter 
believed and taught — 

1. That there is a vital principle. 

2. That this principle is neither chemical nor mechanical in its nature, 
but, on the contrary, is wholly different from any known property of 
matter. 

3. That it resides in, and is peculiar to, animal and vegetable beings. 

4. That it is the immediate cause of all the actions occurring in these 
beings. 

5. That in every animal, life is reducible to one simple property. 

6. That matter cannot originate life; or, in other words, that the life- 
principle never can spring from, nor depend on organization, 

7. That, indeed, organization and life do not in the least depend upon 
each other. 

8. That the principle of life is not necessarily always associated with 
visible organization and spontaneous motion, but, on the contrary, may 
exist in animal bodies devoid of organs and voluntary motion, and pos- 
sessing but the simple power of preservation. 

9. That life is diffused throughout the animal economy, every individual 
particle being imbued with it. 

10. That the idea of life involves and includes the principles of self- 
preservation and action. 

11. That life is not action, but rather the capability of action. 

Such are the leading biological views of the great surgeon-naturalist of 
the eighteenth century. Of some at least of these views, however, Hunter 
appears occasionally to have had some uncertainty, as will be seen from the 
following passages which are distinctly contradictory to some of those 
already quoted. Thus, in the Principles of Surgery — 

" Life appears to be something superadded to this peculiar modification of 
matter, or this modification of matter is so arranged that the principle of life 
arises out of the arrangement, and this peculiar disposition of parts may be 
destroyed, and still the modification, from which it is called animal matter, 
remain the same. If the latter be the true explanation, this arrangement of 
parts, on which life should depend, would not be that position of parts necessary 
to the formation of a whole part or organ, for that is probably a mechanical, or, 
at least, organical arrangement, but just a peculiar arrangement of the most 
simple particles, giving rise to a principle of preservation ; so that matter so 
arranged could not undergo any destructive change till this arrangement were 
destroyed, which is death." 

Here Hunter manifestly regards life as the result of a peculiar molecular 
arrangement of matter. 

And, again, in the section On the Living Principle of the Blood — 

" The living principle in the blood, which I have endeavoured to show to be 
similar in its effects to the living principle in the solids, owes its existence to 
the same matter which belongs to the other, and is the materia vitge diffusa, of 
which every part of an animal has its portion. I consider that something similar 
to the materials of the brain is diffused through the body, and even contained 
in the blood ; between this and the brain a communication is kept up by the 
nerves. I have, therefore, adopted terms explanatory of this theory; calling 
the brain the materia vitse coacervata, the nerves the chordae internuncise. and 
that diffused through the body the materia vitse diffusa. This latter is diffused 
through .the whole solids and fluids, making a necessary constituent part of 
them, and forming with them a perfect whole ; giving to both the power of pre- 
servation and the susceptibiUty of impression, and, from their construction, 
giving them consequent reciprocal action." 



1862.] 



Theories of Life and Organization. 



123 



In this passage our author most unquestionably identifies the vital prin- 
ciple either with the substance of the brain or some matter similar to it. 
His editor, Dr. Palmer, notices this glaring inconsistency, and in vain 
attempts to explain it by saying that these words of Hunter should not be 
taken literally. The fact is, however, that these words are but a modified 
echo of the old neuro-physiology of Hoffman and Cullen — a reproduction 
of the doctrine of a hypothetical nervous fluid, but in a form more substan- 
tial and more in accordance with the strong matter of fact mind of our 
anatomist. 

Judging from his writings, Hunter's mind was eminently self-reliant and 
progressive in its tendencies. More demonstrativ^e than generalizing, and 
always open to conviction, he appears to have held as doubtful, and subject 
to revision or modification, all theories or opinions which could not be 
directly demonstrated, or which did not rest upon the most unequivocal 
proofs and reasoning. Bold and independent in the pursuit of truth, he 
valued opinions just in proportion as they were founded in fact. We gener- 
ally find him ready to sacrifice theory to fact, whether that theory be his 
own or not. We are less surprised, therefore, when Hunter, in one place, 
declares that " life can never rise out of, nor depend upon, organization 
and, in another, that the " principle of life arises out of the arrangement" 
of matter ; when he sometimes says that the life-principle is different from 
all other known agencies, and at other times identifies it with the matter 
of the brain ; w^hen, in one place, he informs us that this matter is diffused 
throughout the body, and in another that it has its seat in the stomach ; 
when he confounds the vital principle with a "certain species of motion,'^ 
and, finally, acknowledges that " life is a property we do not understand, 
we can only see the necessary leading steps towards it." 

It is utterly impossible to reconcile such contradictory statements by sug- 
gesting, as Coleridge has done,^ that the incessant occupation and stupen- 
dous industry of Hunter, and his imperfect acquaintance with the arts and 
aids of logical arrangement, prevented him from fully unfolding and arrang- 
ing his idea of life in distinct, clear, and communicable conceptions. It is 
not in consequence of this "unfriendly medium" that he falls occasionally 
into the "phraseology and mechanical solutions of his age," but rather 
because his views of life and the vital principle were too vague and too 
unsatisfactory to himself to permit him at all times to announce these 
views in positive and consistent language. It is very generally true, even 
among the uneducated, that clear and distinct ideas find expression in 
equally clear and simple terms ; obscure, involved, and contradictory lan- 
guage is the common and suitable clothing of cloudy, indistinct, and uncer- 
tain opinions. The active, progressive, and far-reaching mind of Hunter 
attempted, with eminent success, to combine the practical every-day duties 
of his profession with those comprehensive philosophical inquiries for which 
he manifested such a strong bias, and w^hich, while they in part depended 
upon the details of daily experience, in return tended to bestow upon prac- 
tical medicine a rational character by the elucidation of those fundamental 
principles which connect and harmonize the facts, and so really advance 
the therapeutic art. Hunter, actuated with the true Hippocratic spirit, 
brought reason and philosophy to bear upon experience, and steadily set 
his face against all empiricism. He studied structure not for itself, nor by 

' Hints Towards the Formation of a More Comprehensive Theory of Life. By S. 
T. Coleridge. Edited by S. B. Watson, M. D., Philada. 1848, p. 18. 



124 



Reviews. 



[July 



itself, but with a view to function ; and he sought to explain function by 
studying the economy in disease as well as in health. Hence it is wrong 
to speak of him as a naturalist, or a surgeon, or an anatomist. He was 
all these, and something more. He was a physiologist as well, and a phy- 
siologist, moreover, who, from time to time rising above the mere details 
of his science, ambitiously sought to discover that great primitive fact or 
principle which, in common with many other great minds, he considered to 
exist and be related to the numerous facts of medicine as the law of gravity 
is to the facts of physical science and affinity to those of chemistry. 

In 1793, in the Aphorismi ex Doctrina Physiologiae Chemicae Planta- 
rum appended to his Flora Fribergensis Subterranea, Humboldt defined 
the vital force as the unknown cause which prevents the elements from 
following their original attractive forces." 

"If you attentively consider," he says, "the whole nature of things, you will 
discover a great and permanent difference amongst elements, some of which, 
obeying the laws of affinity, others independent, appear in various combinations. 
This difference is by no means inherent in the elements themselves and in their 
nature, but seems to be derived solely from their particular distribution. We 
call that matter inert, brute and inanimate, the particles of which are combined 
according to the laws of chemical affinity. On the other hand, we call those 
bodies animate and organic, which although constantly manifesting a tendency 
to assume new forms, are restrained by some internal force from relinquishing 
that originally assigned them. That internal force which dissolves the bonds of 
chemical affinity, and prevents the elements of bodies from freely uniting, we 
call vital. Accordingly the most certain criterion of death is putrescence, by 
which the first parts or stamina of things, resume their pristine state, and obey 
the laws of affinity. In inanimate bodies there can be no putrescence." 

Shortly after the publication of these aphorisms, and during his residence 
in Jena, Humboldt wrote his beautiful physiological allegory, entitled The 
Bhodian Genius, which orignally appeared in Schiller's periodical. Die 
Horen, in the year 1795. The language attributed in this allegory to the 
philosophic Epicharmus, shows conclusively that Humboldt at this early 
period of his scientific career believed in the existence of a vital force, pecu- 
liar and unlike any of the forces which actuate and control the elements as 
these exist in inorganic matter. He represents the " crude matters of inor- 
ganic nature" as hastening at their very birth to associate, in obedience to 
the laws of affinity, each with its like, and to enter into new combinations. 
In animal and vegetable bodies the blending of these substances is different. 
" Here vital force imperatively asserts its rights, and, heedless of the 
affinity and antagonism of the atoms asserted by Deniocritus, unites sub- 
stances which in inanimate nature ever flee from each other, and separates 
that which is incessantly striving to unite." 

Two years later (1797), his views appear to have undergone a change, 
for "he declared that he by no means regarded the existence of these pecu- 
liar vital forces as established."^ Writing at Berlin in 1849, he assures us 
that "he has not applied the term peculiar forces to that which may 
possibly be produced only by the combined action of the separate already 
long known substances and their material forces." He regards the chemi- 
cal relations of the elements in different bodies as better criteria by which 

' Versuche iiber die gereizte Muskel- und Nerveiifaser, nehst Vermuthuugen iiber 
den ehemischen Process des Lebens iu der Thier- und Pflanzenwelt., vol. ii. pp. 
430-436. For a defence of the doctrine of vital affinity against the objections of 
Humboldt and Daubenej, see Medical Examiner for January, 1853, p. 3i. 



1862.] 



Theories of Life and Organization. 



125 



to distinguish animate from inanimate substances than voluntary motion, 
the circulation of fluids, and the internal appropriation and fibrous arrange- 
ment of the elements. The difficulty of satisfactorily referring the vital 
phenomena of the organism to physical and chemical laws, depends chiefly," 
he says, "(and almost in the same manner as the prediction of meteorolo- 
gical processes in the atmosphere) on the complication of the phenomena, 
and on the great number of the simultaneously acting forces, as well as the 
conditions of their activity." 

The views entertained and publicly taught by Lawrence concerning the 
vital principle, life and organization, are contained in his Introducto7^y 
Lectures delivered before the Royal College of Surgeons, during the years 
1816, 181t, and 1818. 

He regards the "functions as the offspring of structure," and "life as 
the result of organization."^ He employs the term life to designate the 
"assemblage of all the functions and the general result of their exercise."^ 
With him " organization, vital properties, functions and life are expres- 
sions related to each other ; in which organization is the instrument, vital 
properties the acting power, function the mode of action, and life the 
result."^ 

''In our examination of the phenomena exhibited by living beings," says he, 
" we follow a method analogous to that pursued in the physical sciences. We 
trace the succession of events as far as observation and experiment will enable 
us to pursue them, and we refer them ultimately to a peculiar order of proper- 
ties or forces, called vital, as their causes. These vital properties are the causes 
of vital functions in the same way as chemical affinity is the cause of the com- 
binations and decompositions exercised among the component particles of 
bodies, or as attraction is the cause of. the motions that occur among the great 
masses of matter. Whatever we see in astronomy, hydraulics, mechanics, &c., 
must be ultimately referred, through the concatenation of causes, to gravity, 
elasticity, &c. In the same way the vital properties are the main spring at 
which we arrive, whatever phenomena we may be contemplating in respiration, 
digestion, secretion and inflammation. Among the most remarkable of these 
vital properties are sensibility and irritability — the power of perceiving or feel- 
ing, and that of contracting. To such properties we refer in our ultimate 
analysis of the functions, as the mechanician does to elasticity, when he is ex- 
plaining the motions of a watch, or the astronomer to gravitation, in accounting 
for the course of the heavenly bodies.* * * * 

"We do not profess," he continues, "to explain l\mu the living forces in one 
case, or attraction in the other, exert their agency. But some are not content 
to stop at this point ; they wish to draw aside the veil from nature, to display 
the very essence of the vital properties, and penetrate to their first causes ; to 
show, independently of the phenomena, what is life, and how irritability and 
sensibility execute those purposes, which so justly excite our admiration. They 
endeavour to give a physical explanation of the contraction of a muscle, and to 
teach us how a nerve feels. They suppose the structure of the body to contain 
an invisible matter or principle, by which it is put in motion. iSuch is the 
fiop^ow or impetum faciens of Hippocrates, the Archeus of Van Helmont, the 
Anima of Btahl, Materia Vitae of Hunter, the calidum innatum, the vital prin- 
ciple, the subtle and mobile matter of others.^ * * -x- * seems to me," he 
proceeds, " that this hypothesis or fiction of a subtle invisible matter, animating 
the visible textures of animal bodies, and directing their motions, is only an 



' An Introduction to Comparative Anatomy and Physiology ; being the two 
Introductory Lectures delivered at the Royal College of Surgeons, on the 21st and 
25th of March, 1816. By Wm. Lawrence, F. R. S., &c. London, 1816, p. 115. 

2 Ibid., p. 120. 3 Ibid., p. 121. 

* Ibid., pp. 150-2. 5 Ibid., pp. 165-6. 



126 



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example of that propensity in the human mind, which has led men at all times 
to account for those phenomena, of which the causes are not obvious, by the 
mysterious aid of higher and imaginary beings.'" 

It will thus be seen that Lawrence clearly and distinctly ignores the 
existence of a vital principle, and treats it as a mere chimera. Somewhat 
inconsistently with the foregoing remarks, he asserts, in another paragraph, 
that the peculiar phenomena of organized matter present no analogy to 
those which are treated in chemistry, mechanics, and other physical sciences, 
and that any reference, therefore, to gravity, to attraction, to chemical 
affinity, to electricity or galvanism, can only serve to perpetuate false 
notions in physiology and to draw us away from the proper point of view, 
in which the nature of living phenomena and the properties of living beings 
ought to be contemplated.^ 

Finally, as if not quite sure of his ground, he concludes with this lan- 
guage:— 

" To say that we can never arrive at the first cause of vital phenomena would 
be most presumptuous ; but it is most true, that all the efforts to penetrate its 
nature have been equally unsuccessful from the commencement of the world to 
the present time."^ 

A year later we still find our author, in the Reply to the Charges of Mr. 
Abernethy, with which he prefaces his introductory lecture of 1817, assert- 
ing that " life is the assemblage of all the functions, is immediately depend- 
ent on organization,* denotes what is apparent to our senses ; and cannot 
be applied to the offspring of metaphysical subtlety or immaterial abstrac- 
tions without a complete departure from its original acceptation ; without 
obscuring and confusing what is otherwise clear and intelligible."^ He 
thinks that the "notion of life is too complicated, embraces too many par- 
ticulars to admit of a short definition, and varies in the different kinds of 
animals as their structure and functions vary."^ He is occasionally con- 
tradictory and inconsistent with himself. We have just seen that he calls 
life "a result of organization." In another place he says it ''would be 
unmeaning and nonsensical to call life a property of organization he 
ridicules " those who think it impossible that the living organic structures 
should have vital properties without some extrinsic aid," and declares that 
"just in the same proportion as organization is reduced, life is reduced; 
exactly as the organic parts are diminished in number and simplified, the 
vital phenomena become fewer and more simple ; and each function ends 
when the respective organ ceases."^ 

The crude and uncertain character of the biological views of Hunter, 
Humboldt, and many other savants who have indelibly stamped with the 
seal of their genius the scientific record of the past century, is, undoubtedly, 
due to their ignorance of the true biological method. The certainty of a 
science depends upon the method which rules in it and by which it is suc- 
cessfully cultivated, and this method is bound up in, and indicated by the 
fundamental law, the primitive fact or principle of the science. For phy- 
siology, and, therefore, for medicine, which is based upon it, there is a 
certainty as philosophical, though not as rigidly exact, as that which 
chfiracterizes the mathematical sciences themselves. But this certainty is 

' Ibid., p. 174. 2 Ibid., p. 161. ' Ibid.,p 178. 

Lectures on Comparative Anatomy, Physiology, Zoology, and the Natural His- 
tory of Man. By Wm. Lawrence, F. R. S., &c., London, 1848. Bohn's edit., p. 5. 
^ Ibid., pp. 42, 43. ^ Ibid., p. 64. ' Ibid., p. 58. ^ Ibid., p. 73. 



1862.] 



Theories of Life and Organization. 



127 



yet prospective, and will remain so until the primitive law of physiology 
and medicine is discovered and demonstrated beyond cavil. 

Attempts to discover this law have not been wanting. Their history 
has been recorded in the words solidism, humeralisra, vitalism, chemicism ; 
in the archens of Paracelsus, the animal spirits of Descartes, and others, 
the corpus pneumaticus of Bacon, the ^ther of Newton, the anima of 
Stahl, the nervous fluid of Willis, Baglivi, Hoffman, and Cullen, the irrita- 
bility of Glisson, the vis insita and vis nervosa of Haller, the materia vitse 
of John Hunter, the vis vitse of Goertner, the excitability of Brown, the 
nisus formativus of Blumenbach, the sensorial power of Darwin, the organic 
spirit of Bring, the conservative principle of Blane, and the vis medicatrix 
naturae of a thousand and one writers. 

All these attempts were premature and more or less defective, so they 
failed to establish a correct theory of life. Physiologists of the present day 
possess strong reasons for believing that the establishment of such a theory 
must be preceded by the formation of a positive and satisfactory theory of 
organization ; a theory so comprehensive as to embrace all forms of animal 
and vegetable life, from the most minute and simple to the most gigantic 
and complex. Ah^eady a theory of structure, at once simple and grand, 
has been erected upon the labours of many zealous naturalists and physiolo- 
gists, prominent among whom are Cuvier, Bichat, and Schwann. 

Both zoology and physiology are greatly indebted to Cuvier for the 
progressive activity which they suddenly exhibited in the latter part of the 
eighteenth century. This illustrious naturalist, who, for the comprehen- 
siveness, if not the depth of his intellect, stands alone in the annals of 
natural history, was the first to associate the study of the earth's strata 
with the study of the fossil remains found therein ; the first, in other words, 
to co-ordinate the facts and principles of geology and the physics of the 
globe with comparative anatomy and physiology. It was in 1795 that he 
announced the great principle that the study and classification of animals 
should be founded rather upon their internal organization than their ex- 
ternal peculiarities. The establishment of this principle did much to trans- 
fer zoology from the hands of the mere observer of external characters to 
those of the anatomical investigator and experimenter. It substituted an 
exact and reliable method of classification for the artificial system bequeathed 
to the world by Linnaeus. In physiology it paved the way for the solution 
of the great problem of the duplex life of man, and the connection of this 
life with organization. It paved the way to the elucidation of this subject 
in so far as it rendered the laws of the correlation of forms and the subor- 
dination of parts available to physiology. These fundamental laws of com- 
parative anatomy were discovered and applied by Cuvier with the most 
brilliant results. He was not slow in perceiving and duly appreciating the 
wonderful adaptation of the parts which make up the living mechanism. 
He saw that every organ in an animal is related to all the others, and they, 
in turn, to it. Observation, comparison, and reflection, faculties which he 
possessed in an eminent degree, led him to conclude that the form of an 
organ being given, we might readily determine the forms of all the other 
organs with which it had been associated. Thus, the form of the teeth, 
and, in certain cases, even the form of a single tooth, determines the shape 
of the condyle of the lower jaw ; the form of the condyle determines the 
character of the glenoid cavity which receives it, and this cavity indicates 
the contour of the zygomatic arch, the appearance of the temporal fossa, 
&c. The form of all these parts determines the mode of mastication, and 



128 



PvEVIEWS. 



[July 



this latter expresses the form of stomach and intestines, and the kind of 
digestion. 

In details of this character Cuvier was eminently great. But he used 
them chiefly to determine species and genera, and to found a classification 
of the animal kingdom, more exact and natural than the famous system of 
Linneeus. With their physiological bearing he troubled himself but little. 
And this is the more remarkable since the functions are bound together by 
a correlation even more intimate than that which associates the organs 
themselves. Thus, respiration, when it is accomplished in a circumscribed 
respiratory organ, as the lungs in man, cannot do without a circulation, 
since the blood must be brought into contact with the organ which receives 
the air, and it is by means of the circulation that the blood is transported 
from one part of the economy to another. The circulation cannot dispense 
with irritability, for this irritability determines the contractions of the heart, 
and, consequently, the movements of the blood. Muscular irritability, in 
its turn, is in harmony with the nervous system. If one of these functions 
change, the others alter also. If the circulation is wanting, the respiration 
can no longer be circumscribed. It must go on throughout the whole body, 
as in insects ; for if the blood is not made to seek the air, the air must be 
carried to meet the blood. The quantity of respiration everywhere deter- 
mines the vigour, rapidity, and even the kind of motion. The motion 
which requires the greatest muscular energy is flight ; the bird has, conse- 
quently, a double respiration. It respires by means of lungs, and through- 
out its whole body ; for the air having traversed the lungs, is thence con- 
veyed into large sacs in the abdominal cavity, and, finally, into the cavities 
of the long bones. Throughout this entire tract the blood is aerated. The 
movements of mammals are more limited, and their respiration is simple. 
The mammal respires by its lungs only, and these lungs are confined to one 
part of the body. But its respiration though simple is complete, for all the 
blood in its body passes through the lungs before being distributed to the 
tissues for the purposes of nutrition. The reptilia with feeble and sluggish 
movements combine a very imperfect respiration. Their pulmonary circu- 
lation is only a part of the general circulation. Hence, only a part of their 
blood is aerated. An impure blood circulates throughout the body, their 
temperature is lessened, their movements are slow and interrupted by long 
repose ; they hibernate. On the other hand, fishes, still lower in the ani- 
mal scale than reptiles, have a complete pulmonary circulation ; but in so 
far as it is aquatic, it is imperfect, for the air breathed is only that which is 
mechanically mixed with the water. Fishes like reptiles have a cold blood, 
and their movements require, in general, but little muscular energy. Thus 
it will be seen that four kinds of respiration prevail in vertebrated animals ; 
the double respiration of the bird, the simple but complete respiration of the 
mammal, and the incomplete respiration — incomplete in two different ways 
• — of reptiles and fishes. These four varieties of respiration determine four 
species of motion in these animals, to wit : the flight of the bird, the walk- 
ing, leaping, or running of the mammal, the crawling of the reptile, and 
the swimming of the fish. 

Respiration and digestion are harmonically connected. The more ex- 
tensive the respiration, the more rapid and powerful the digestion. In 
birds the digestion is most rapid, in reptiles it is slowest. The bird 
astonishes us by the frequency of its repast, the reptile by the length of its 
fast.^ 

' See Flourens' " Cuvier, Histoire de ses Travaux." Paris, 184r',pp. 151-156. 



1862.] 



Theories of Life and Organization. 



129 



Other examples might readily be given to show how all the organs, all 
the functions, all the modifications of organs and functions are made for 
each other, and for a great and predetermined object. 

Enough has been said, however, to show how much the philosophy of 
physiology is indebted to the Cuvierian method of contrasting animals by 
their organs, instead of their external characters. But valuable as is this 
method to the physiologist and the pathologist too, a still more valuable 
one was indicated by the celebrated Bichat, of whom it has been said that, 
" if we compare the shortness of his life with the reach and depth of his 
views, he must be pronounced the most profound thinker and the most 
consummate observer by whom the organization of the animal frame has 
yet been studied."^ Though inferior to Cuvier in the comprehensiveness 
of his knowledge, he was decidedly superior to that great naturalist in his 
physiological acumen and in the grandeur of the generalizations which he 
sought to establish. He boldly dealt with the most momentous topics in 
biological science ; he dealt with them with a degree of enthusiasm and 
laborious earnestness rarely to be met with. He investigated the human 
organism with a view to obtain some clear and definite notion concerning 
the causes and nature of life. He sought to establish a theory of life by 
investigating the physical and chemical properties of the structural elements 
of the human body. He saw that something more was required than the 
mere comparison of organs. He saw in the labours of Carmichael Smyth, 
Bonn, Borden, and Fallopius the germ of a great method, of a great in- 
strument of research. With them he recognized the physiological value 
of the tissues ; but his conception of this value was far greater and more 
philosophical than theirs. With an industry almost unparalleled, he re- 
solved all the organs of the body into twenty-one tissues, essentially dis- 
tinct, but possessing in common the two great properties of extensibility 
and contractility. " These tissues he subjected to every sort of examina- 
tion ; he examined them in different ages and diseases, with a view to 
ascertain the laws of their normal and pathological development. He 
studied the way each tissue is affected by moisture, air, and temperature, 
also the way in which their properties are altered by various chemical sub- 
stances, and even their effect on the taste. Piuel informs us that in the 
course of these investigations he opened in one winter no less than six 
hundred bodies. 

Let us contemplate the biological picture which his genius bequeathed to 
us in the work whose title stands at the head of this article. 

Life in the entire organic world is twofold. There is an organic or 
vegetable life, and there is an animal life also. These two lives may exist 
separately or in combination with each other. The former is common to 
all living beings, and is strictly essential ; the latter is confined to one group 
only of living beings, and is not essential to the maintenance of the organ- 
ism. Vegetable life is fundamental, and upon it animal life, wherever it 
exists, is superposed. Organic or vegetable life can exist alone ; animal or 
relative life can exist only in combination with the former. Vegetable life, 
however, is not on this account more important than animal life ; for, 
although it cannot be denied that in Ijy far the greater number of organized 
creatures the latter is merely supplementary to the former, yet we find, as 
we ascend the organic scale, that vegetative life loses the importance arising 

' History of Civilization iu England. By H. T. Buckle. Vol. i. p. C39. 
2 Buckle, op. cit. 

No. LXXXVIL— July 1862. 9 



130 



Revie-ws. 



[July 



from its fundamental character, and serves merely to sustain and minister 
to that animal life which attains its highest expression in the moral and 
intellectual attributes of man. Organic life is limited to the triple proceSvS 
of reproduction, assimilation, and disintegration. Animal life exhibits 
itself in spontaneous motion, and in moral, mental, and instinctive mani- 
festations. The first life is for the most part internal, unconscious, and 
continuous ; the second life is in the main external, conscious, and inter- 
mittent. These two lives are governed by different laws, which, though 
intimately connected, are to a certain extent antagonistic to each other. 
They find their highest expression in man, who, in virtue of his organic 
life, exists solely for himself, while through his animal life he is enabled to 
move, to feel, and to judge, and is thus brought into active relation with 
his fellows and with external nature in general. 

Now the twofold life of man is inseparably connected with his organiza- 
tion. The organism is the necessary and active medium through which 
this life is manifested. We say necessary and active, for all that we know of 
life is through structure, and structure eternally modifies the laws of life. 
There being two lives exhibiting themselves in peculiar ways, we might 
suppose, cL priori, that there are two kinds of structure — two classes of 
organs. To get a good idea of the double life of man we may contrast 
the organs whose actions constitute the varied phenomena of life. Only 
by a careful study of these phenomena in reference to the organism, on the 
one hand, and the conditions of existence, on the other, can we hope to 
understand the nature of life. 

The organs or instruments of the vegetable life of man are characterized 
by a certain irregularity, some of them being symmetrical and some not. 
Those of his animal life are remarkably and uniformly symmetrical; every- 
where they exist in pairs. There are two eyes, two ears, two nares sepa- 
rated by a median partition, two hands, two feet, two arms, two legs ; there 
are two brains, or, rather, two hemispheres, a right and a left — two spinal 
marrows, or, rather, two symmetrical halves of the medulla spinalis. All 
the nerves of animal life originate in pairs, or are symmetrical. With these 
facts the ancient physiologists were perfectly familiar. They drew from 
the head to the foot a median line, and so divided the human body into 
two lateral and symmetrical halves. Indeed, there exists an old book 
written in Latin and entitled " De Homine Dextro et Sinistro," or " Man, 
Right and Left." 

The organs which subserve the vegetative or organic life of man are not 
all as symmetrical as Bichat maintained, but are irregular, in so far as some 
of them exist in pairs and some do not. Thus, the stomach, intestines, 
liver, spleen, pancreas, &c. are non-symmetrical. The lachrymal, salivary, 
and mammary glands, the kidneys, testicles, and ovaries are symmetrical, 
as also, strictly speaking, are the penis, vagina, uterus, &c. The heart, 
like the sphenoid and ethmoid bones of the skull, is symmetrical; the lungs 
are nearly so in man and many of the mammals, as the lama, the rhinoceros, 
and the porpoise. It is entirely symmetrical in birds, in the Chelonians, 
most of the Saurians, and all the Batrachians. The branchige, or gills, are 
symmetrical in all the fish, in the mollusks, in the Crustacea, and in the 
worms. The tracheae are symmetrical in the insects. On the other hand, 
air-breathing mollusks have a single pulmonary cavity. In the reptilian 
class, some of the lizards and nearly all the serpents have one lung very 
small in comparison with the other; in some of the serpents the small lung 



1S62.] 



Theories of Life and Organization. 



131 



disappears entirely. In the boas the short lung is one-half as long as the 
other ; in the typhlops it is one-fourth. ^ 

The organs of animal life being double, while those of organic life are 
for the most part single, the former life is enabled to rest, to stop part of 
its functions, and to renew them again. For organic life, on the contrary, 
there is no rest but in death. Organic life never sleeps. It is a stranger 
to the alternations of sleeping and waking, phenomena so characteristic of 
animal life. The brain may sleep, and the whole economy be benefited 
thereby ; the wearied muscle may rest and come out of that rest with 
renewed vigour. For the heart and the lungs there is no rest, no cessation 
from toil. With them, to rest, were it even for a moment, is to die. 

The wonderful processes of nutrition, disintegration, and calorification, 
processes by which the living body is built up, broken down, and heated in 
the self-same moment, admit of no interruption. Being single, admitting 
of no supplementary aid, they are by their very nature incessant. On the 
other hand, the functions of animal life are by their very nature adapted 
to periods of activity and periods of repose. Who can think earnestly 
while he runs quickly or toils briskly with his arms. If the right arm is 
fatigued the left can relieve it. This is true of the legs, of the eyes, of the 
hemispheres of the brain, &c. 

The essential intermittence of animal life renders it capable of improve- 
ment ; the equally essential continuousness of organic life deprives the 
latter of this capability. Comparison must precede improvement. The 
comparison of one state with another leads to the rectification of error in 
the past or present, and its avoidance in the future. Organic life, not being 
interrupted or broken into stages, is not amenable to comparison. Animal 
life, on the contrary, is divided into such well-marked periods of activity 
and periods of repose that its stages are eminently comparable with each 
other.- It is in consequence of this repeated comparison that the unintelli- 
gible cry of the infant is gradually perfected into the copious, flexible, and 
glowing language of the high caste races of men ; that memory, reflection, 
and judgment are matured and strengthened; that the senses are brought 
to such a wonderful state of perfection ; and that the vocal muscles of the 
skilful singer are enabled to produce such extraordinary musical effects. 

But the theory of life promulgated by Bichat was a failure. It failed, 
not, however, because the method was erroneous, but because the applica- 
.tion of the method was not extensive enough. It was impossible for Bichat 
to accomplish more than he did in his short, laborious, and brilliant life. 
Had his life been prolonged it is difficult to say what he would not have 
accomplished. We must judge him less by the results of his labour than 
by, the philosophical spirit which actuated his efforts. With a loftiness of 
thought to which the anatomists and physiologists of his day were entire 
strangers, he attempted to connect the fundamental object of philosophical 
anatomy with the fundamental theory or principle of biology. He attempted 
to find the connecting link between the statics and dynamics of physiology. 
Now, the fundamental object of philosophical anatomy, if we may use the 
formula of Comte, is the "reduction of all the tissues to one primordial 
elementary tissue, from which they are developed by modifications more 
and more special and profound, first of structure and then of composition."^ 

^ See "Flourens' " Cuvier," edit, cit., p. 184, and " De la Vie," p. 29. 

2 Comte's Philosophy of the Sciences ; being an Exposition of the Principles of 
the Cours de Philosophie Positive of Auguste Comte. By Gr. H. Lewes, Loudon. 
1853, p. 188. 



132 



Reviews. 



[July 



Bichat resolved all the organs into twenty-one tissues. This was a great 
step. To reduce these tissues to one primordial form — the cell — years of 
patient and laborious research were required by the lynx-eyed men of the 
microscope. The day in which Bichat lived was not prepared for this 
generalization. It was not eifected, indeed, until so late as the early part 
of the present century, and the labours of very many men were required to 
bring it to maturity. 

The doctrine of cell-genesis, the broadest generalization at present known 
to statical physiology, began with Malpighi in the recognition of the blood- 
corpuscles as small globules, in the latter half of the seventeenth century, 
and received many of its early facts through the industry of Leuwenhoek, 
Hewson, and Haller, whose labours tended strongly to establish an indi- 
viduality of organization unknown apparently to the ancients. It was not, 
however, until so late as 1816, that the great idea of the structural unity 
of the organic world began to take a definite shape in the minds of physio- 
logists. It was in that year that Treviranus announced the broad generali- 
zation that all the tissues were reducible to three morphological elements — 
the amorphous, fibrous, and globular. But this announcemeiit, though 
regarded as remarkable for its correctness, and far in advance of the know- 
ledge of that day, was afterwards shown not to be broad enough. The 
great work of Heusinger, which appeared six years afterwards, the discovery 
of the nucleus of the vegetable cell by Robert Brown, in 1833, the investi- 
gations of Purkinje and Deutsch upon cartilage, corpuscles, and the process 
of ossification, the researches of Valentin, in 1835, upon the formation of 
])igment-cells around pre-existing nuclei, and the comparison instituted by 
him between the cells of vegetable tissue and those of cartilage, the obser- 
vations of Sehultze upon the histology of the blood, and particularly upon 
the cell-relations of the blood-particles, the labours of Henle, Yogel, Donne, 
Boehm, and many others, and, finally, the announcement of the law of 
developmental unity for all vegetable cells made by Schleiden in his great 
work on phytogenesis, published in 1838, were all necessarily preliminary 
to the discovery and enunciation of the cell theory promulgated by Thomas 
Schwann, in 1839. This theory is essentially one of structure and organi- 
zation, and as such should be regarded as the indispensable forerunner of 
the true conception of the theory of life. Life we can study only through 
or by means of its phenomena, and these are exhibited in their simplest and 
most easily recognized form in the growth and development of the simple 
cell — the structural unit of the entire organized world. But growth and 
development, philosophically viewed, are simply modes or varieties of 
organic motion. The study of life, therefore, narrows itself down to the 
study of cell-motion as produced and influenced by the physical conditions 
of life.^ But these conditions are many, constantly varying in intensity, 
and the facts which we possess concerning them have been accumulating 
for ages. Already out of these facts is now being developed a theory 
bolder and more comprehensive by far than that of cell-genesis — a fitting 
companion to the latter — and strictly dynamical or biological in character. 
We allude to the "correlation doctrine," so-called, which seeks with no 
little promise of success to resolve all the active external conditions of life 
into one universal imponderable force or principle — itself, perhaps, the 
essence or principle of life. 

' "Daily advances in science," says Dr. Gull, in the oration delivered before the 
Hunterian Society, in ISfil, " make it more and more probable that organized beings 
ai'e tlie necessary development of the physical conditions of our globe." 



1862.] 



Theories of Life and Organization. 



133 



These two great theories of cyto-genesis and physico-vital correlation, 
the one strnetural, the other dynamical ; the one explanatory of form and 
function, the other of the active influencing cause of form and function, are 
beginning to be regarded by physiological thinkers as the two broad roads 
leading to a generalization more simple, more beautiful, and still more com- 
prehensive than any with which biological science has yet been crowned. 

Pressing on with industrious and philosophic zeal along the former of 
these two roads we find Remak, Tirchow, Weber, Redfern, His, Bottcher, 
Billroth, Paget, and many others. Prominent among these, for his volumi- 
nous and valuable labours in this field of research, we may particularize, 
without injustice to his cotemporaries, the celebrated Rudolf Tirchow, who, 
following Remak in discarding the theory of the evolution of cells from a 
structureless blastema, as advocated by Schleidan and Schwann, has become 
the leader of the new pathological school which bears upon its banner the 
fundamental doctrine — Omnis cellula e cellula. 

" Especial difficulty," writes this learned biologist, " has been found in answer- 
ing the question, from what parts of the body action really proceeds — what parts 
are active, what passive. ***** The cell is really the ultimate mor- 
phological element in which there is any manifestation of life, and we must not 
transfer the seat of real action to any point beyond the cell. ***** it 
is almost impossible for any one to entertain more mechanical ideas in particular 
instances than I am wont to do when called upon to interpret the individual 
processes of life. But I think that we must look upon this as certain, that, 
however much of the more delicate interchange of matter which takes place 
within a cell, may not concern the material structure as a whole, yet the real 
action does proceed from the structure as such, and that the living element only 
maintains its activity as long as it really presents itself to us as an independent 
whole. 

On the other highway of research leading to the true theory of life we 
encounter, among many others, Vanuxem, Metcalfe, Grove, Carpenter, 
Faraday, Mayer, Radcliffe, Hiutou, Leconte, &c. 

According to Leconte there are four plans of material existence rising 
successively in importance above each other. Elementary existence consti- 
tutes the lowest. Chemical compounds (the mineral kingdom) form the 
second. The third plane is that of vegetable existence; the fourth and 
highest that of animal existence. Matter can pass from the lowest to the 
highest plane only by degrees, and in consequence of a greater expenditure 
■of force than is necessary to keep it in the plane of elementary existence. 
Any amount of matter returning to a lower plane by decomposition must 
set free or develop a force which may raise other matter from a lower to a 
higher condition. "Thus decomposition," he says, "must in every case 
develop force, which force may take the form of heat as in combustion, or 
electricity as in electrolysis, or may expand itself in forming chemical com- 
pounds, or even in organizing matter."- Decomposition, he thinks, is 
necessary to develop the force by which the organization of food or nutri- 
tion is effected. The egg during incubation evolves carbonic acid, and, 
probably, water also, and loses weight, but gains in organization, the latter 
being in proportion to the former. Heat is here indirectly transformed 
into a vital force causing decomposition of a part of the organic matter, 

' Cellular Pathologv, as based upon Plijsiological and Patliological Histologj. By 
Rudolf Virchow. London, 1860, p. 3. " 

The Correlation of Physical, Chemical, and Vital Forces, and the Conservatiou 
of Force in Vital Phenomena. American Joarual of Science and Arts, vol. xxviii. 
p. 305. 



134 



Keviews. 



[July 



whicli latter, by descencliDg from the organic to the mineral plane, sets free 
a force which may raise the remainintr portion into a slightly higher con- 
dition. The decarbonizatiou of the blood by the action of oxygen upon it, 
though serving for the production of animal heat, and the removal of effete 
materials, may have the higher purpose of yielding force to the blood itself 
for the maintenance of its vital state. The exercise of our organs leads to 
their increased growth in consequence of the fresh organizing force supplied 
by the decomposition of the tissue. Indeed, to use the language of a very 
suggestive contributor to the Cornhill Magazine, "there is a ceaseless 
round of force-mutation throughout nature, each one generating or chang- 
ing into the other. So the force which enters the plant is heat, or light, 
&c., and is stored up in its tissues, making them organic ; this force, trans- 
ferred from the plant to the animal- in digestion, is given out by its muscles 
in their decomposition, and produces motion, or by its nerves, and consti- 
tutes the nervous force."^ 

We have thus, in brief terms, indicated the direction which physiological 
inquiry is at present taking with regard to the subject under notice. Like 
two divisions of an army marching by different but converging routes to 
the attack of a fortified stronghold, the students of biology are steadily 
advancing along two separate paths to become masters of a theory of life 
and organization which shall deprive medicine of its empiricism and give 
to it a scientific and rational character. J. A. M. 



Akt. XIII. — EpiJejDsy: its Symptoms, Treatment, and Relation to other 

Chronic Convulsive Diseases. By J. Russell Reynolds, M. D., Loud. 

London, 1861. 8vo. pp. 360. 
Epileptic and other Convulsive Affections of the Nervous System, their 

Pathology and Treatment. By Charles Bland Radcliffe, 31. D. 

Third edition, Loud. 1861. 12 mo. pp. 312. 

The method of numerical analysis has not ceased to enrich medical sci- 
ence and medical art since it was first explained and illustrated by Louis. 
His most distinguished English disciple. Dr. Walshe, dedicated to him a 
treatise on diseases of the lungs and heart, which has become classical, and 
now he himself receives from Dr. Reynolds the inscription of the most 
important work which has yet appeared upon a- disease at once the most 
terrible in its phenomena and the most obscure in its pathology. Thus it 
is that truth grows into power. Dr. Reynolds' medical training peculiarly 
fitted him for the task he undertook. Accurate and discriminating obser- 
vation is at the basis of all reasoning about the causes and nature of dis- 
eases; but to diseases of the nervous system none of those physical methods 
are applicable which have unravelled so many knotty questions concerning 
disorders of the lungs and heart, of the digestive and urinary organs. Lentil 
very recently the functions of different portions of the nervous system 
were imperfectly determined and consequently the interpretation of their 
derangements was in a great degree conjectural. To appreciate and explain 

' Physiological Riddles. Cornliill Magazine, July, August, September, and Oc- 
tober, 18G0. 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



135 



the phenomena of epilepsy, therefore, it became essential that the physiology 
of the nervous system and the pathology of its various diseases should be 
familiarly known, so that both deductively and inductively the mechanism 
which produces symptomatic epileptiform convulsions and idiopathic epi- 
lepsy should be demonstrated. This preparatory examination Dr. Reynolds 
performed in his work on "The Diagnosis of Diseases of the Brain, Spinal 
Cord, Xerves, and their Meninges," in which he showed himself a faithful 
disciple of the doctrines which Marshall Hall spent his life in elucidating, 
while in the present treatise he has more thoroughly combined physiological 
principles deduced from experiment with the pathological inductions of a 
minute numerical analysis of clinical phenomena. We greatly err in our 
estimate of his conclusions if future observation shall materially impugn 
their accuracy. 

Dr. Radcliffe's new edition of his well-known essay is in fact almost, 
as already stated in our number for January last (see pp. 198-201), a 
new work, for he tells us that the whole has been rewritten and recast. 
Its distinguishing feature consists in the elaborate and very ingenious argu- 
ment of the author in support of the theory of epilepsy which he adopts, 
and which we shall again refer to. 

Since the publication of Herpin's treatise ten years ago, all writers upon 
epilepsy have seen that to arrive at any correct conclusions in regard to the 
nature and cure of the disease, idiopathic cases of it are alone suitable for 
analysis, however useful the analogy of other spasmodic affections may be 
in illustrating the nature and the proximate cause of convulsion in general. 
In truth it seems now to be pretty certain that in their various forms con- 
vulsion, and also paralysis, are little more than general symptoms, requiring, 
indeed, for their expression, the intervention of the nervous system, but 
neither denoting with certainty the particular organ of that system which 
is affected, nor the nature of its derangement. Symptomatic epileptiform 
convulsions, i. e., convulsions identical with those of epilepsy but attributable 
to a definite organic cause, are as various in their origin as the organs of 
the body from which a mechanical irritation- may be carried to the medulla 
oblongata and reflected thence to the muscular system, or as the conditions 
of the blood capable of exciting the specific spasms. But apart from these 
there is a class of cases in which neither during life nor after death can any 
starting-point be discovered for the irritation which results in convulsion, 
and these we are obliged to regard as examples of true idiopathic epilepsy. 
Yet it is quite possible that the time may come when even such cases may 
prove to be examples in which a more recondite but not less powerful irri- 
tating cause acts in the same manner as the mechanical causes of epileptic 
spasm now ascertained to exist. However this may be, it is certain that 
the nature and phenomena of epilepsy will be most clearly exhibited by a 
searching analysis of cases in which the essential phenomena of the disease 
are isolated and disengaged from all accidental conditions which would 
otherwise tend to obscure them. 

In a chapter introductory to the pathology of nervous diseases Dr. Rey- 
nolds presents some considerations upon the nature of disease in general, in 
which it is assumed that the vital actions of an organ depend upon interstitial 
physical changes within it. Although it is afterwards stated that of vital- 
ity and organization neither is antecedent to the other in point of time, 
and however difficult it may be to conceive of life abstractly from matter, 
it appears to us a doctrine fraught with danger in which such an independ- 
ent existence is denied. It must still be admitted that living organized 
matter being given, we can conceive of no change in the phenomena of its 



136 



R E T 1 E W S . 



[July 



existence without a corresponding: change in its organization, or that upon 
whicli its organization depends, its nntrition. Convulsions, tlierefore, must 
dei^end upon modifications in the physical condition of the organs through 
which they are manifested; and for convulsions of the same kind the imme- 
diate or proximate organic cause must always be the same, however different 
may be the remote cause. No other belief is consistent with the funda- 
mental postulate of the uniformity of the laws of nature. Pr, Reynolds 
assumes that the /■/' v r/ t^^^ cause of convulsions is always the same, and 
consists in an al ' crease in the nutritive changes in the nervous 

centres, and that the /\ causes are those which tend to induce such an 
abnormal increase. Even if these propositions were admitted to be true, it 
is not very clear in what manner or to what degree they throw light upon 
convulsions generally, or specially upon its epileptic form. For, after all, 
we must admit that lioth the proximate and remote causes are specific, since 
their operation produces efi'ects sui generis : and that in idiopathic epilepsy, 
no remote organic cause of it being discoverable, there is a connate predis- 
position to this peculiar form of disease. The predisposition may consist 
merely in the inability to tolerate or resist certain external or internal 
impressions, but if it leads to epilepsy its specific causative influence is none 
the less real. Again, if we admit that certain remote causes generate a 
molecular condition of the nervous centres which issues in convulsions of a 
particular kind, we are obliged also to admit that in certain individuals an 
innate peculiar susceptibility of those nervous centres exists which implies 
that they at the same time possess a peculiar molecular constitution. But 
whether this peculiarity consists in something less or something more than 
belongs to the perfectly normal type is purely conjectural. Quite probably 
it belongs to the same category of organic conditions that create tempera- 
ments, and those peculiarities of temper, disposition, and intellect which 
distinguish classes of men and individuals from one another. 

Leaving, for the present, the arduous question of the nature of epilepsy, 
we shall follow Dr. Reynolds in some account of its phenomena. He 
defines epilepsy to be "a chronic disease characterized by the occasional 
and temporary existence of loss of coiiseiousiies>. witli or without evident 
muscular contraction." and insists upon its I'eiiig an idiopathic disease dis- 
tinct from eccentric convulsions, from tox:pirj:c sp:isnis, from the convulsions 
attendant upon organic lesion of tlie cerebro-sninal centre, and, in fact, 
from every other known and appreciable malady. He therefore blames 
Dr. Sieveking, Bright, and others who have attempted to base a natural 
history of the disease upon cases in which definite lesion.s existed equally 
with those in which none such were discoverable. By the author's method, 
if strictly observed, it is evident that tlie essential elements of the disease 
must become disengaged from others which are only associated with it acci- 
dentally. Other writers have professed to follow it, but none, hitherto, 
whose accuracy in diagnosis has withstood a searching criticism. 

The symptoms of epilepsy are considered under two general heads — 1, 
the interparoxysmal, and 2, the paroxysmal. It is evident that a parox- 
ysmal disease must be associated with some peculiarities during the intervals 
between the paroxysms, however difficult ir may be to detect them in recent 
cases and whenever the attacks occur at long intervals. In the present 
instance, the brain being the organ which is chiefly implicated, it is only 
natural, to suppose that some intellectual peculiarities should be observed. 
Such, indeed, is the statement made by the greater number of writers upon 
the subject; and, because idiocy and insanity are frequently associated with 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



137 



epilepsy, they have often been regarded as its natural concomitants or con- 
sequences. Dr. Sieveking does not remember a case "of ordinary severity" 
without some flaw in the mental faculties ; but Dr. Reynolds' analysis 
shows — 1. That epilepsy does not necessarily involve any mental change ; 
2. That considerable mental impairment exists in some cases, but that it 
is the exception, and not the rule; 3. That women suffer more frequently 
and more severely than men ; 4. That the commonest failure is loss of 
memory, and that this, if regarded in all its degrees, is more frequent than 
integrity of that faculty. These are his most important conclusions, to 
which it must be added that in thirty-eight per cent, of the whole number 
of cases analyzed by him no mental alteration was discoverable. 

Regarding sensational phenomena between the paroxysms, this author 
finds — 1. That severe headache is an exceptional pjhenomenon, but that 
slight and occasional headache is common ; 2. That women are more liable 
to it than men ; 3. That vertigo also is rare, but less so in the female than 
in the male sex, and is of the kind which has been termed "subjective." 
In regard to disturbed motility it appears, among other conclusions — 1. 
That evidences of it are presented in a large majority of epileptics; 2. That 
of the three forms of motor disturbance, clonic spasm is the most frequent, 
tonic spasm the least frequent, and tremor occupies an intermediate posi- 
tion ; 4. That all of these forms are most common in the male sex, and 
clonic spasm especially so ; 5. That their high development is most frequent 
in the female sex; 6. That trachelismus is an exceptional form of muscular 
disturbance ; and 7. That disorders of motility are more frequent than dis- 
turbances of the mental condition. 

"The general picture of the epileptic," says Dr. Reynolds, "is that of an 
individual with trembling hands and uncertain movements, whose gait is awk- 
ward, and whose limbs, or whole frame occasionally, exhibit startings, or present 
a restlessness resembling slight chorea. It must be remembered, however, that 
the picture may be that of a strong and robust man, with every movement re- 
sembhng that of health and ease." 

The organic condition of epileptics during the intervals of their attacks 
it is of great importance to determine correctly, since a particular view of 
it, and the one which is taken by Dr. Radcliffe, is closely related to the 
theory of the disease which he illustrates and defends. This writer asserts 
that the circulation of the epileptic is habitually feeble, and his hands and 
feet cold, but Dr. Reynolds, after showing that Tissot, Portal, MaisoR- 
neuve, Georget, Cooke, Miller, and Prichard make opposite statements, 
proves, by an analysis of his own cases, not only that epile'psy may coexist 
with phy.sical health and strength considerably above the average, but that 
the. coexistence of epilepsy with such extremely robust health is more 
common than its coexistence with extremely impaired health. He makes 
the further remark, which is an important one, that there are no special 
departures from organic health which are characteristic of epilepsy, but 
that when impaired it is in the following order of functions, viz., tempera- 
ture, strength, and nutrition. On the whole, and regarding the entire 
state of health, animal and organic, he concludes that epileptics moderately 
or slightly impaired in health are more than twice as numerous as those 
whose condition is more seriously damaged. 

The symptoms of the epileptic pjarojysm are considered by Dr. Reynolds 
under the two forms usually described of epilepsia mitior, with local tonic 
spasmodic movements, and epilepsia gravior, with general tonic and clonic 
convulsion, to which are added simple loss of consciousness without con- 



138 



Eeviews. 



[July 



vulsion, and o:eiieral or partial convulsion without complete loss of con- 
sciousness. The simplest and mildest type is that without evident spasm, 
but with a sudden and temporary, but absolute arrest of both perception 
and volition, and followed by a confusion of mind, dulness of apprehension, 
and depression of spirits. Or it may be preceded and accompanied by 
vertigo and partial loss of muscular power, or, rather, of mental control 
over it. Even if standing, the patient rarely falls, and often, as conscious- 
ness returns, he resumes the action he was engaged in at the moment of 
the seizure, without being fully aware of what has taken place. ISText to 
this in gravity, but of greater frequency, is epilepsia mitior, in which the 
degree of spasm varies from a slight contraction of a few muscles, usually 
of the face, to a tonic contraction and temporary rigidity of the whole 
body. It may be unassociated with evident vascular changes, or, again, 
the face may be pale and the pulse feeble ; or, on the other hand, there 
may be duskiness followed by flushing of the countenance and throbbing of 
the heart and arteries. 

We cannot follow our author in his account of the phenomena of epilepsia 
gravior. It does not differ materially from that of previous writers, but it 
is rendered much more complete than theirs by an analysis of the pheno- 
mena, particularly in regard to their relative frequency and their succession 
and combination. It will well repay perusal. In regard to that form of 
the paroxysm in which there is convulsion without complete loss of con- 
sciousness, we learn that it has been observed and described by several 
writers, and particularly Maisonneuve, who relates four cases. Dr. Rad- 
cliffe furnishes an example, and Dr. Reynolds five others, of this singular 
form of disease. In one of these, the symptoms were those of sudden tonic 
contraction in the muscles of the face and neck, with suffused face, embar- 
rassed respiration, twisting of the head, and slight tremulous rigidity of 
the arms, the whole lasting from three to five seconds, and the patient not 
only affirming afterwards, but evidently exhibiting at the time, persistent 
consciousness. In regard to the epileptic aura, the author states that he 
never met with anything like that described by the old authors under this 
name, but in one case the jerking of an arm, and in another the drawing 
up of a leg, extended apparently towards the trunk, and passed into a 
general paroxysm so soon as it reached the latter ; in a third case, a stab- 
Ibing pain in the arm preceded the attacks ; and in all these the fits might 
occasionally be arrested by grasping firmly the thigh or upper arm, or by 
forcibly extending the limbs. 

Under the general head of the etiology of epilepsy we find that Dr. Rey- 
nolds' experience leads him to believe that an hereditary tendency to the 
disease is much more common than it is generally represented to be by 
recent writers upon the subject. In regard to age and sex, the analysis of 
his observations teaches that the approach of puberty is a powerful predis- 
posing condition, and that females under ten and males above twenty years 
are most likely to become epileptic. A case is mentioned in which the first 
attack occurred at the age of seventy, and without any assignable cause. 
In about one-fourth of his cases Dr. R. could discover no cause whatever of 
the attacks, and in nearly one-fifth the cause was doubtful; of the remainder, 
psychical causes were equal in number to all of a physical nature, including 
in the latter category eccentric irritation, general organic changes, and- the 
action of external agents. 

If we seek to learn the natural history and relations of the different 
forms of attack we find that epilepsia gravior is twice as frequent as epilep- 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



139 



sia mitior ; but that for the latter to exist alone is an excessively rare 
occurrence. Yet it is not a preliminary stage out of which the graver 
form of the disease is subsequently developed, nor, on the other hand, is 
it an after consequence of that form; but it is an attendant pheno- 
menon, absent in some cases, and occurring in others, but at no particular 
period in the development of the disease. According to the author's expe- 
rience, which agrees with that of Delasiauve, regular periodicity is excep- 
tional in epilepsy, and in only three women could he detect any habitual 
relation between the attacks and the catamenial state. At the same time 
he admits that in a majority of cases there is an approximation to periodi- 
city in the recurrence of the attacks. Important conclusions relative to the 
influence of frequency of attack are these ; frequency of attack and mental 
deterioration are more commonly associated than are opposite conditions; 
a high rate of frequency is more commonly associated with slight degrees 
of motor disturbance ; and while individuals whose attacks were of very 
frequent occurrence exhibited, positively, no defect in their general health, 
those, on the contrary, in whom the organic condition was much below par, 
presented only a low rate of recurrence. "It is evident, therefore, that a 
high rate of frequency of recurrence is not determined by organic ill health ; 
but that, on the contrary, a notable frequency of attack is associated with 
unimpaired general health." Nor is there any constant relation between 
the age of the patient and the rate of frequency of the attacks ; for, although 
they are most apt to recur frequently in persons under the age of seventeen 
years, youth by no means necessarily entails a high rate of frequency. 
Indeed, when the commencement is very early, as during the first twelve 
years of life, the rate of frequency is commonly low. Nor, again, has the 
total duration of the disease any relation to the frequency of the attacks. 

The mental condition associated with epilepsy is a subject of peculiar 
interest, for it has been generally believed that sooner or later in the pro- 
gress of the disease the mind becomes impaired, and reason is lost in 
dementia or mania. A close analysis of cases, however, proves that there 
is no relation between mental failure and a hereditary predisposition to 
epilepsy, nor any between this state of mind and the age at which the dis- 
ease commences, nor between this state and the mere duration of epilepsy. 
It appears, however, contrary to Esquirol's opinion, that when epilepsy 
commences after puberty the intellectual condition is impaired more rapidly. 
When the general organic health is exceedingly good there is a greater 
tendency than exists in epileptics per se, to deterioration of the mental 
condition; but so soon as the general health fails, and in the degree to 
which it fails, does the mental condition relatively improve. At the same 
time, the mental condition of epileptics cannot be v/holly referred to their 
state of general health, for a sound state of mind or any degree of mental 
failure may coexist with perfect organic health, or with the opposite con- 
dition. Just as little can the mental failure of an epileptic, or its degree 
when present, be referred to the number of attacks he has experienced, but 
it has a constant and direct relation to the frequency of the seizures. The 
converse is not, however, true. Frequency of seizure is not necessarily fol- 
lowed by mental failure; it is one, but neither the sole nor a necessary con- 
dition of this result. Again, it follows from Dr. Reynold's analysis that 
when attacks of E. mitior are present the mind is more frequently affected, and 
affected gravely, than when the individuals are free from the slighter seizures. 
Yet, as these may exist without entailing mental incapacity, it follows that 
they are not essential to the result. This author concludes, that while 



140 



Reviews. 



[July 



neither form of attack necessarily entails npon the sufferer mental injury, 
yet when both forms coexist mental failure occupies a more marked and a 
more direct relation to attacks of E. mitior than to those of E. major. 
These conclusions materially modify the general statement of Dr. Radcliffe 
that "the natural tendency of epilepsy is assuredly towards dementia,-' even 
when qualified as it is by the admission that it is possible for an epileptic 
to liv€ many years, and to have many fits without losing the powers which 
are necessary to render him an agreeable and serviceable member of society. 
(P. 139.) 

In regard to the motor condition, and its state in regard of general 
organic health, Dr. Reynolds shows that those individuals in whom tremor, 
clonic, and tonic spasm are present do not exhibit any higher rate of fre- 
quency of attacks than do those from whom such disturbances of motility 
are absent, and, therefore, infers that the causes of the attacks and of the 
disturbances alluded to are not identical, and that neither is the cause of 
the other. Nor is there any constant relation, and, therefore, not any in- 
ter-dependence between tremor, clonic spasm, or tonic spasm, on the one 
hand, and deficiency, nutrition, strength, or temperature on the other. 
Tremor and also clonic spasm are apt to be associated with impaired strength 
and temperature ; but tonic spasm does not affect the nutrition. 

It is remarked by Dr. Reynolds that in describing the consequences of 
epilepsy sufficient care has nat been taken to distinguish between conditions 
which may properly be so called and those which are due to other diseases. 
An examination of his own cases leads him to the conclusion that the 
duration of epilepsy exerts a slight and only doubtful influence upon the 
patient's health, and it is quite as likely to be impaired in a recent as in a 
protracted case. He also infers from the same data, that " epilepsy does not 
produce, i. e., that it, per se, does not cause failure of memory, of apprehen- 
sion, or of ideation, tremor, clonic spasm, or tonic, loss of nutrition, tem- 
perature, or strength." And he shows that the opposite opinion is attri- 
butable to the very heterogeneous character of the cases denominated 
epilepsy, which have served as materials for the greater number of those 
who have written concerning the disease. 

The proper complications of epilepsy, or " those conditions which may 
be held to depend more or less directly upon the attacks," are few in number. 
Epileptic mania, the author remarks, has a character of its own. Gener- 
ally furious, sometimes ecstatic, in other cases it is marked by dulness and 
depression of spirits ; or, on the other hand, by preternatural gayety.^ 

Apoplexy would seem, d priori, to be a very natural termination of the 
repeated and violent attacks of congestion of the head which are charac- 
teristic of the fully developed attack of epilepsy. But, as in so many other 
instances, experience contradicts the anticipations of, we will not say science, 
but reasoning; Dr. Reynolds assures us that "it is exceedingly rare to find 
that actual hemorrhage has occurred;" and adds, "no single instance of 
such an occurrence has presented itself in my own experience." He is 

' Upon this subject the reader will consult with interest and advantage a memoir 
hj M. .Jules Falret {Archives Generates de Mid., Dec. 1860, and Avril and Oct. 1861). 
The author describes minutely different phases of mental aberration with an incon- 
trollable propensity to commit violence wliich characterize the vertiginous and 
convulsive forms of epilepsy, and those cases in which the epileptic character of 
the disease is unrecognized or misconstrued. The subject is one which demands 
the attention of the medical jurist, and it is particularly in its relations to criminal 
law that M. Falret has illustrated it. 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



141 



unable to trace the character of the relations between idiocy and epilepsy. 
Of poTaJysis he makes the same remark as of apoplexy. It stands in an 
accidental, not an essential, relation to epilepsy. 

The patJioIof/y of epilepsy is discussed by Dr. Reynolds in a very able 
manner. He brings to its elucidation a thorough acquaintance with all the 
most recent results of anatomical and physiological investigation, and sub- 
jects them to a rigid criticism guided by the only sufficient test, clinical 
experience. Unfortunately, clinical experience is apparently not uniform 
and consistent in its teachings, for it is invoked with equal confidence by 
those who maintain the most opposite doctrines. This is true even in 
regard to pathological questions, the elements of which are comparatively 
stable and readily appreciable by the senses; it is much more so when the 
phenomena to be studied are fluctuating and not uniformly associated with 
the same, or, it may be, w^ith any material change of structure. 

Dr. Reynolds propounds the following questions : 1. What is the organ 
on whose modifications the symptoms of epilepsy depend ? 2. What is 
the nature of its change ? 3. How was that change induced ? 4. What 
are the links of connection between that change and the phenomena of the 
disease ? 

To the first question pathological anatomy answers, 1, that no structural 
change is constantly found at all periods of the disease ; and 2, that some 
lesions are of more common occurrence than others. But as none are uni- 
form, or even approach to uniformity in occurrence among the lesions which 
may be considered as efficient causes of epileptic phenomena, no one of these 
lesions can be regarded as the essential cause of the paroxysm. The obser- 
vation of Sehroeder van der Kolk, that enlargement of the capillary vessels 
and granular degeneration of the medulla oblongata are to be found in the 
bodies of epileptics is very important and significant; but this observer 
himself speaks of the lesions in question, not as the causes, but as the 
"proximate result of the fits." Physiological experiment furnishes a dif- 
ferent answer, while it corroborates the conclusion just expressed. Brown- 
Sequard, Kussraaul, and Tenner have proved by experiments upon animals 
whose cerebral hemispheres and cerebellum had been removed, that epilepti- 
form convulsions may be excited in them by irritation of the medulla oblon- 
gata, and that this irritation may act efficiently whether it be applied directly 
to the nervous centre in question or indirectly to it and to the spinal marrow 
by irritating the remote branches of nerves supplying the skin and other 
organs. But convulsive movements do not constitute the whole of epilepsy. 
Its more characteristic symptom is the loss of consciousness which attends 
tliem, and which necessarily implies some changed condition in the cerebral 
hemispheres. The ancient opinion prevailed until recently, and was accepted 
and extended even by Marshall Hall, that the phenomenon in question is 
due to congestion of the brain. Yet it is evident that the evidences of 
cerebral congestion present themselves late in the paroxysm, whereas loss 
of consciousness is its earliest symptom. It had long ago been shown by 
Sir Astley Cooper that compression of the carotids and consequent anemia 
of the brain will induce loss of consciousness and epileptiform attacks. 
Clinical observation furnishes abundant proof of the same pathological 
fact. Dr. Brown-Sequard and others have demonstrated that the arteries 
of the brain-meninges contract through reflex stimulation, the centre of 
such a reflexion being the medulla oblongata. 

"There appears, therefore," says Dr. Rej'nolds, "no reason for doubting that 
the immediate cause of loss of consciousness is arrest of the cerebral circula- 



142 



Reviews. 



[July 



lion, owing to the contraction of the vessels, through irritation propagated 
along the vaso-motor nerves from the medulla oblongata ; and thus the latter is 
shown to be the organ wherein both elements of the epileptic paroxysm have 
their origin." 

Not that this nervous centre originates those elements, but only that it 
is the channel through which the organic causes operate to produce the 
phenomena of the attack. 

What, then, is the nature of the morbid change ? 

"In early cases," says Dr. Eadcliffe, citing the conclusions of Schroeder van 
der Kolk, " in early cases of epilepsy, it is true, we may fail to find anything 
characteristic even here [?". e., in the medulla oblongata] ; but in confirmed cases 
this organ is harder than natural, from the interstitial deposit of a minutely 
granular albuminous matter, or else softened, swollen, and presenting evident 
signs of fatty degeneration. The posterior half is also redder and more hyperae- 
mic than it ought to be, even when the patient had not died in a fit; and on 
making a more minute examination, the bloodvessels are seen to be dilated to 
thrice their natural dimensions, and with their walls much thickened. These 
vessels, moreover, are seen to be especially dilated in the course, of the hypo- 
glossus nerve and corpus olivare in epileptics who were in the habit of biting 
their tongue in a fit, and in the course of the roots of the vagus in epileptics 
who were not in this habit." 

But all of these changes are, as we have already seen, effects and not 
causes of that which occasions epileptic convulsions. In the early attacks, 
Dr. Reynolds remarks : — 

"Nutrition is affected dynamically and temporarily; there is no recognizable 
departure from textural integrity ; there is merely the difference that exists in 
health and in all organs between action, over-action, and repose ; after a time, 
and by frequent repetition of attacks, the changes, induced temporarily, become 
permanent, and the texture, which is the product of foregone nutrition processes, 
is altered statically and persistently." 

Now, as regards the nature of the irritation which determines the con- 
vulsive attacks, it must be borne in mind that all the movements of the 
respiratory and other organs upon which the sustenance of life depends, 
are reflex actions, as well as many others which can also be performed by 
the operation of the will. Dr. Reynolds reminds us that the unconscious- 
ness of the epileptic paroxysm has its analogue in ordinary sleep, a state 
w^hich has never yet been explained, and that under the influence of emotion 
the phenomena of convulsions occur in daily life and as parts of our healthy 
activity. The conclusion must therefore be that in epilepsy the functions 
of the reflective centre are changed in degree rather than in kind. 

But if changed in degree, is there increased or diminished action ? 
Upon this question Dr. Reynolds and Dr. Radclifife arrive at diametrically 
opposite conclusions, the one finding in all the phenomena of the fit " evi- 
dence, not only of disturbed equilibrium, but of distorted, misdirected, and 
exaggerated power," and the other concluding that the facts adduced by 
him " will scarcely warrant the idea that epilepsy is connected with any- 
thing like over action of the nervous system." Dr. Radclifife attempts to 
show by a very ingenious induction that the blood, instead of being a 
stimulus to muscular contraction, tends, on the contrary, to prevent it, 
and that its withdrawal promotes first irregular muscular contraction, and 
finally, after death, tonic rigidity. In like manner, after a long experi- 
mental and rational inquiry, it seems to him " no improbable idea that 
muscular elongation is coincident with the presence of electrical action in 
Biuscle and nerve, and that muscular contraction is coincident with the 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



143 



absence of this action. It would seem to be no improbable idea that there 
is a state of polarity in living muscle during relaxation which produces 
relaxation, and that contraction is nothing more than the necessary result 
of the muscle being liberated from this state." Relaxation, then, is, 
according to Dr. Radcliffe, the active condition of muscular fibre, contrac- 
tion "nothing more than the necessary result of the muscle being liberated 
from this state, and left to the operation of the attractive force which is 
inherent in the physical condition of the muscular molecules." Applying 
this theory to the phenomena of epilepsy. Dr. Radcliffe maintains that the 
activity of the medulla oblongata, so far from being augmented during the 
attack, is deprived of its normal power and abandons the muscular system 
to its inherent organic contractility. Upon this view we think it would 
be sufficient to remark that it renders extreme if not insurmountable the 
difficulty of explaining the clonic character of epileptic convulsions. It 
adapts itself, as the author shows, to the phenomena of rigor mortis, and 
in some degree to those of tetanus, but it leaves unexplained the source 
from which convulsed muscles derive the power of regaining their normal 
condition, since, according to the hypothesis, they begin their morbid con- 
traction with a loss of power. 

But to return to the question of increased or diminished action in epi- 
lepsy. As Dr. Reynolds very appropriately remarks, the terms " action" 
and " over-action" used in reference to the medulla oblongata imply both 
the capacity for receiving impressions and the faculty of giving forth motor 
impulse. In epilepsy the former appears to be constantly in excess, as Dr. 
Brown-Sequard has pointed out, and this is almost the sole causative ele- 
ment of the paroxysm in epilepsia mitior, whereas in the graver forms of 
the disease motor excitability is predominant. , The susceptibility of the 
motory nervous centre is proved even between the paroxysms by the readi- 
ness with which the nervous equilibrium is disturbed and attacks are pro- 
duced by emotional or moral commotion. This double exaggerated suscep- 
tibility of the functional activity of the medulla oblongata and upper part 
of the spinal axis appears to be the immediate cause of the convulsive 
phenomena of epilepsy. But what awakens it and with it the convulsive 
and other characteristic phenomena of the disease ? Undoubtedly in many 
cases an eccentric irritant may be detected, or something which may be 
held to act as such, although the supposed causes differ from one another 
as. widely as organic disease of the brain, mental excitement, the mechanical 
irritation of a distant nerve, and some more or less definite vitiation of the 
blood. But in many other cases no such influence can be demonstrated, 
and we are therefore compelled to admit a peculiar and innate susceptibility 
to the disease. Such a susceptibility it is doubly imperative that we should 
recognize when epilepsy is purely hereditary, or the causes which develop 
it are of slight intensity, or appear to acquire their morbid influence by 
frequent repetition. Of the latter class are those excitations which induce 
a state of the organism analogous to the epileptic condition. 

" In this manner," says Dr. Reynolds, " pertussis passes into convulsion — 
coition or masturbation into epilepsy ; and in the same way the latter has been 
developed by violent laughter from tickling the feet." 

"The facts would appear to show," says Dr. Radcliffe, "that the habitual 
state between the paroxysms of ordinary epilepsy is one which is marked by a 
weak and slow pulse, by cold extremities, and by shallow, or retarded, or sighing 
breathing, and which is most marked in this manner when the danger of the 
attack is most imminent." 



144 



Reviews. 



[July 



And again : — 

" The interparoxysmal state in ordinary epilepsy is marl?;ed by wanting vigour 
both in the circulation and in the respiration." 

But debility is denied by Dr. Reynolds to exist in more than one-half of 
the cases of epilepsy. He also proves that, instead of a low condition of 
vitality favouring the recurrence of the fits, the reverse is true ; and the 
paroxysms are shown to be most frequent and severe in those whose organic 
vigour is unimpaired. Moreover, in this class of patients both forms of 
the disease, E. gravior and E. raitior, are apt to be combined, whereas in 
impaired health E. gravior is mainly the form which the paroxysms assume. 
Again, as we have already seen, the mental power has a stronger tendency 
to deteriorate when the general health is remarkably good, and relatively 
to improve when the latter declines. Such are among the results of a 
clinical study of epilepsy, and, as Dr. R. remarks, it is not a sufficient 
answer to assert that debility is the cause of convulsion in that disease, 
however clear the evidence may be that cerebral anaemia is a cause of con- 
vulsion. Convulsion is not epilepsy, but only one of its symptoms. 

Among the conditions favourable to the production of epilepsy, the 
cachexia? are often excited, probably for no better reason than that, because 
a tangible and demonstrable cause could not be discovered, the equally 
mysterious conditions denoted by the name just mentioned might be accused 
without much risk of their innocence being demonstrated. Dr. Reynolds 
states that fifty-six per cent, of the epileptics examined by himself were 
free from all cachexia ; they were in perfect health of body. We cannot 
but feel surprise that so acute a physician as Dr. Radcliffe should cite, 
apparently in support of this doctrine, a passage like the following, which 
it is little to the credit of Dr. Todd that he should have written : — 

" I hold that the peculiar features of an epileptic seizure are due to the gradual 
accumulation of a morbid material in the blood, until it reaches such an amount 
that it operates upon the brain in, as it were, an explosive manner ; in other 
words, the intluence of this morbid matter, when in suflBcient quantity, excites 
a polarized state of the brain, or of certain parts of it, and these discharge their 
nervous power upon other parts of the cerebro-spinal centre in such a way as 
to give rise to the phenomena of the fit." 

It would be difficult to find anywhere a greater number of gratuitous 
assumptions and illogical deductions crowded into so small a space as in 
these few lines. 

Certain conditions of the economy, however, appear to act as determin- 
ing causes of. epilepsy. In some of them, it is true, local centres of irrita- 
tion exist, which may operate by a reflex agency, as in puberty, pregnancy, 
and dentition ; in others, smaller in number, there is a morbid nutrition 
change, as in rheumatism and pneumonia. The real value of these elements 
as causes of epilepsy will depend upon the degree of predisposition to the 
disease in cases where they appear to develop it. and this, according to 
Dr. Reynolds' observations, appears to have been very decided. 

The last mode mentioned by this author in which the medulla oblongata 
and the upper part of the spinal axis may become so affected as to produce 
epileptiform convulsions, is the operation of some lesion of the nervous 
system, such as a cerebral or spinal tumour, chronic meningeal inflamma- 
tion, softening of the brain, neuromata, &c. ; but he repeats the important 
oljservation that the clinical history of these cases differs from that of 
idiopathic epilepsy, in that they present superadded phenomena dej-ending 
upon the character of the local lesion iti each case. 



1862.] 



Reynolds, EADCLirrE, Epilepsy. 



145 



Having thus attempted to elucidate the- morbid nature of epilepsy, the 
author proceeds to a rational explanation of the various phenomena of 
the paroxysm. In the first stage, as already explained, loss of conscious- 
ness is attributed to the arrest of the vascular supply by spasmodic contrac- 
tion of the cerebral vessels ; tonic muscular contraction to undue action in 
the medulla oblongata passing dovrnwards to the spinal cord; arrested 
respiration is attributable to closure of the glottis, to fixation of the re- 
spiratory muscles, or to both combined, the second agency being the most 
operative by far. The epileptic cry he regards as a spasmodic phenomenon, 
and not as expressing distress ; and pallor of the face as produced by the 
same sort of hifluence which occasions loss of consciousness, viz., spasmodic 
contraction of the arteries. This explanation of the former ^symptom 
originated with that singularly sagacious observer Whytt, whose great 
merits it has required the lapse of a century to disclose. Duskiness of the 
face is admitted to be caused by the trachelismus" of Dr. Marshall Hall, 
by whicl? the return of the blood through the cervical veins is prevented. 
Dilatation of the pupil is, like pallor, the result of over-action in the dilat- 
ing fibres of the iris ; and feebleness of the radial pulse is due either to 
muscular tonic spasm concealing it at the wrist or arresting it at the 
shoulder. 

In the second stage, continued loss of consciousness is owing to conges- 
tion rather than anaemia of the cerebral hemispheres, " In the first stage 
the epileptic's brain had no action — now it has a morbid action ; in the 
former it may be said to have been dead or defunct — in the latter to be 
poisoned or narcotized." Clonic convulsion is a consequence of the circu- 
lation of carbonized blood ; laborious respiration and tracheal gurgling 
are obviously effects of asphyxia primarily induced by tonic spasm, as are 
also palpitation of the heart and throbbing of the arterial pulses. It is 
during the clonic stage that the contents of the bladder, rectum, and vesi- 
cul83 seminales are discharged, and that profuse lachrymation and salivation 
occur. These phenomena are all due to pressure upon the several receptacles 
and glands. The after stage of stupor," when this exists, is one of ex- 
haustion and partial paralysis, and its severity appears to be "in proportion 
to the amount of asphyxia, the latter being determined by the duration of 
the tonic stage of the attack." From an analysis of the conditions under 
which the epileptic aura is observed, the author regards it as a peculiar 
induced condition of the peripheric expansion of certain centripetal nerves, 
and this one of exalted impressibility or functional activity. When thus 
changed, these nerves are capable of setting up abnormal motor reactions 
upon the application of slight stimuli. 

The phenomena of the interparoxysmal condition, in their relation to 
the central fact of the disease, are explained by Dr. Radcliffe as follows : 
As to mental failure, it is important to observe that this does not exist iii 
more than one-third of the cases ; in the others it is very analogous to the 
decay which accompanies old age, and results chiefly from incapacity for 
attention, which in its turn is associated with a listless indifference to every- 
thing. As we have already seen, it is not proportioned to any of the phe- 
nomena of the disease, and Dr. R. thinks it must depend " upon a peculiar 
condition of the brain, induced (but only in some individuals) coetaneously 
with that which is the cause of the paroxysms." That this deterioration 
of the functions of the brain is due to its impaired structure is most pro- 
bable, because it is in direct proportion to the frequency of the attacks. 
No. LXXXYIL— July 1862. 10 



146 



Reviews. 



[July 



Time is therefore wanting for the complete repair of the damage which the 
brain's structure has sustained during the paroxysm. 

The chapter on Diagnosis, as might be expected, illustrates the peculiar 
skill of the author in a field in which he has already been distinguished. The 
greater number of convulsive affections are in little danger of being con- 
founded with epilepsy by acute and accurate observers. Eccentric convul- 
sions, although individually presenting all the phenomena of epilepsy, do 
not constitute that disease. If the irritating cause which occasions them 
is removed before they have had time to produce organic changes in the 
brain, they cease to occur. As Dr. Reynolds remarks, the distinction is a 
real one, and of the highest importance in the direction of treatment.. In 
one word, it is essential to the idea of epilepsy that its paroxysms should 
arise in the first instance, and recur at intervals subsequently without the 
operation of the same definite exciting cause. Similar remarks are appli- 
cable to toxasraic convulsions. As to those which proceed from tumours, 
softening, chronic meningeal inflammation, &c., of the brain, tjie inter- 
paroxysmal symptoms, if attentively observed, will generally afford sufficient 
ground to base a diagnosis upon. .The distinction of such diseases from 
one another is not involved in the present discussion. In general terms, 
these groups of organic cerebral disease differ from epilepsy in the following 
particulars : — 

" There is extreme irregularity in the period of recurrence of convulsions 
symptomatic of cerebral disease. Their appearance is preceded and accompa- 
nied by aggravation of the other symptoms, and often followed by the develop- 
ment of new phenomena. The attacks have rarely all the characters of fully 
developed epileptic paroxysms ; either consciousness is partially retained, or 
there are no asphyxial changes ; or the irregular spasms continue for a much 
longer period ; or they are confined within narrow limits ; or they are not fol- 
lowed by coma." 

Of the prognosis of true epilepsy, Dr. Reynolds offers no flattering ac- 
count. Out of eighty-one cases, eight only absolutely recovered, or ten 
per cent. Various circumstances influence the prognosis. Thus, when the 
cause is most obscure, there is most reason to apprehend the existence of a 
strong inherent proclivity to the disease, and, therefore, to indulge but a 
slender hope of removing it. In regard to age. Dr. R. found, at the time 
of the fits ceasing, the age of his patients that recovered was between fifteen 
and thirty-two, and the disease had commenced at ages between thirteen 
and thirty-one. In regard to the mental condition of epileptics, the pre- 
sence of hereditary predisposition appears not to exercise an unfavourable 
influence; but the reverse is true as regards the female sex, and the com- 
mencement of the disease after childhood and puberty. As a general rule, 
when the mind has suffered much, it has suffered early. It has been already 
stated that intellectual impairuient is more commonly associated with a 
vigorous condition of the health than with the reverse. The danger to 
life in an epileptic is a somewhat remote contingency; and in true epilepsy 
the attacks rarely leave behind them either paralysis or other change of 
motility, or any notable injuries to the organs, or functions of special 
sense. 

We were not surprised to find so small a portion as only thirty pages of 
Dr. Reynolds' work devoted to the treatment of epilepsy, and half of these 
to the narration of illustrative cases. From his point of view the records 
of cures of this affection are not trustworthy, because they comprise ^11 



1862.] 



Reynolds, Radcliffe, Epilepsy. 



147 



epileptiform convulsions as well as simple idiopathic epilepsy. To sepa- 
rate the two categories from one another, and accurately estimate the value 
of the therapeutic element in each, would be impossible. The records of 
the last twenty years are less chargeable than earlier ones with this defect, 
but they are by no means free from it. As Dr. Reynolds remarks, "The 
first essential is diagnosis : organic disease of the brain, diathetic disease, 
and eccentric convulsions must be eliminated carefully: we must know what 
we have to treat." This is an unquestionable truth ; and when we observe 
how it has been neglected in the purely empirical treatment of the disease, 
we cannot feel surprised at the farrago of drugs to which anti-epileptic 
virtues have been attributed. On the other hand, we are indisposed to 
subscribe to the proposition that the rationalistic method has failed " in a 
still larger number, because the theories upon which it has rested have often 
been abundantly wrong." Had the theories been demonstrably true, they 
would never have served as a basis for treatment — they would only have 
accomplished what the author of this work has so happily attempted, and 
furnished to the physician cases identical in their nature, in the treatment 
of which he would still have been obliged to employ remedies empirically. 
The disease isolated by observation, and the remedy discovered empirically, 
are the two essential factors in all scientific cures. 

When, therefore, Dr. Reynolds lays down, as indications in the treatment 
of the epileptic condition, "the reduction of undue excitability," and "the 
improvement or the maintenance unimpaired of the mental powers and the 
general health," and mentions as means thereto " the administration of 
sedative medicines, the establishment of counter-irritation, and the main- 
tenance of a certain regimen," he merely formulates what universal empiri- 
cal observation has taught. Science endeavours to justify art, but does 
not add a tittle to the powers of art; she may prevent a wasteful expendi- 
ture of art's resources, but renders them not a whit more or less intrinsically 
valuable. The indication "to reduce excitability" is not a discovery of 
science, it is the instinctive teaching of common sense. Nothing is practi- 
cally gained by formulating in those words what the records of medicine 
show was in every physician's mind from the beginning. "Excitability," 
as we call it, was patent in the muscular and other disordered phenomena 
of the disease ; experience had taught the power of certain agents to allay 
disorders more or less similar to those of epilepsy; and these agents, which 
afterwards were designated by the common epithet, narcotics, were resorted 
to in the hope of curing epilepsy also, i. e., the convulsive disorder which 
appeared to constitute the disease. It were well, therefore, that we should 
remember that the natural growth of knowledge is inductive, and always 
proceeds from particulars to general propositions, and that any of the latter 
not so developed are generally fallacious, if not necessarily false. 

In reviewing the particular narcotics and sedatives which are intended to 
fulfil the indication of "reducing excitability," Dr. Reynolds relies, perforce, 
upon the testimony of experience, and includes in his list agents as different 
as opium and hyoscyamus, conium and belladonna, Indian hemp and Selinum 
palustre. From what we know of the mode of operation of these medi- 
cines it would be difficult to refer their curative power to a common quality, 
even that of diminishing general sensibility. The operation of some among 
them, opium and belladonna, for instance, appears to be directly antago- 
nistic. Leaving any criticism of principle, it is of more interest to know 
that, as a physician. Dr. Reynolds has found all of these and some other 



148 



Ketiews. 



[July 



analo.s^ous medicines, including chloroform, palliatives and nothing more. 
Bromide of potassium, oxide of zinc, ammonio-sulphate of copper, and 
nitrate of silver, he has no confidence in, althouglr of the second he admits 
that he cured one case by it, and that many were improved for a time. In 
stating that "according to Herpin's own account of it, but little value can 
be attached to its employment,'- there appears to be an error, since the 
author referred to ranks it second of all the remedies that he tried. The 
various bitter and metallic tonics are useful. Dr. R. believes, only in special 
conditions of the general health, as iron when ansemia is present. Dr. 
Radclilfe, perhaps looking too steadily at his theory of debility as the root 
of epilepsy, expresses a more favourable opinion of tonics, but particularly 
of the nutrient tonic cod-liver oil, and other oils, and is disposed to think 
that "they may have some claim to be regarded as of special use, not only 
in cases of epilepsy, but also in all other cases in which the brain and nerv- 
ous system are in need of a tonic." 

Counter-irritation finds no favour in Dr. Reynolds' eyes; nor does frugal 
diet; and he regards the success of Heberden, Cheyne, and others by the 
latter means as exceptional. Dr. Radclilfe expresses a similar opinion. 
Moderate but not fatiguing exercise is recommended by both of these writers. 
In sleeping the head should be raised, and the extremities should always be 
kept warm. 

The second object of treatment is "to improve, or maintain unimpaired 
the mental health," and the whole may be summed up in this phrase, as 
applicable to the mind as the body — exercise without fatigue. All mere 
emotional excitements should be shunned, but whatever occupies and inte- 
rests without exhausting is beneficial. In a few remarks upon the treatment 
of the attacks, Dr. Reynolds furnishes some illustrative proof of the value 
of arresting the progress of the aura by compression, and refers to the 
occasional benefits of cauterization as used by other physicians. 

On the whole, the impression left upon the reader's mind by the con- 
cluding portion of this work will, perhaps, be one of disappointment; for, 
after the clear and cogent demonstrations of the preceding divisions relative 
to the pathological history of epilepsy, one cannot avoid anticipating an 
equally satisfactory exposition of the cure. But the brevity of this portion 
is perhaps not one of its least recommendations. There being little to say, 
the author wisely said but little, but yet enough to show that there is no 
specific for epilepsy, nor even any certain method of cure; that on the con- 
trary, the disease will most frequently continue, although its violence may 
be mitigated and its victim's life be rendered comparatively comfortable 
by a due attention to the laws of health. A. S. 



1862.] 



Saurel and Roc hard, Naval Surgery. 



149 



Art. XIV. — Traite de Gliirurgie Navale. Par Louis Saurel, Chirur- 
gien de la Marine, Professor agrege a la Faculte de Medecine de Mont- 
pelier, Correspondant de la Societe de Chirurgie de Paris; Suivi d'un 
resume de lecons sur la service chirurgical de la flotte. Par le Docteur 
J. Rochard, Chirurgien en chef de la marine, Professor a PEcole de 
medecine navale du port de Brest, Oflficier de la Legion d'honnenr. 
Illustre de 186 planches intercalees dans le texte. 8vo., pp. 592, + 104. 
J. B. Balliere et Fils. Paris, 1861. 

Treatise on Naval Surgery. By Louis Saurel, Surgeon of the Navy, &c. , 
followed by a summary of lectures on the surgical service of the fleet. 
By Doctor J. Rochard, Surgeon in Chief of the Navy, &c. &c. Paris, 
1861. 

The practical application of the principles and art of surgery to the 
treatment of wounds and injuries and certain maladies when they occur on 
board of ships of war constitutes naval surgery; and so the application of 
the same principles in the management of wounds and certain diseases when 
they occur in an army constitutes military surgery. The principles and art 
of surgery, whether practised in ships of war, in an army in the field, or in 
civil life, are the same. In an army and in a navy, the surgeon is often 
forced to resort to measures and means in caring for his patients which 
circumstances suggest ; but which are or should be always consistent, 
nevertheless, with the broad principles taught in the schools. 

The work of surgeon Saurel might be cited in evidence of the remark 
just made. It is a very simple summary of the mode of treating the wounds 
and injuries most frequently occurring on board ships of war, according to 
received principles. And although he states the causes of contusions and 
wounds and fractures — consisting chiefly in the unsteadiness of the ship, 
which render men who climb the rigging liable to fall, and those on the 
decks to be injured by the falling or tumbling about of various objects 
which, even with every precaution, sometimes break loose from their fasten- 
ings, in storms especially — he offers no suggestion to guide us in the man- 
agement of cases which, from the constant motion of the ship, he declares 
to be often very difficult. He tells us that the operation for the relief of 
strangulated hernia may become necessary, even during the prevalence of a 
gale ; but, although he declares it to be difficult for the surgeon and hazard- 
ous to the patient, we look in vain for instructions upon the mode of securing 
both patient and surgeon during the operation against the violent rolling 
or pitching of the ship. He might have added that the use of a trephine 
on the skull may be necessary while the motions of the vessel are so great 
as to render locomotion upon the decks very inconvenient, if not difficult 
and hazardous, even to people experienced upon the sea. But such opera- 
tions have been and can be safely accomplished, even under such unfavour- 
able circumstances, by fixing both patient and operator in such manner that 
they will be simultaneously affected by the alternating movements of the 
vessel. 

Surgeon Saurel tells us that patients with fractures cannot be treated in 
their hammocks, and that the iron bedsteads supplied to the ship's hospital, 
in the French navy, are objectionable, because, being fixed to the deck, they 



150 



Reviews. 



[July 



partake of all the motions of the vessel. The nautical cot, used in the 
British and American navies, answers tolerably well, provided that the 
patient, with a fractured lower extremity, is dressed before the cot is hung 
up where it is to swing. He urges that fractures occurring on board ship 
should be reduced at once, and the permanent dressings be applied, because 
the surgeon receives the patient immediately after the accident, before swell- 
ing can occur. He also is of opinion that a double inclined plane is not 
applicable to the treatment of any fracture of the thigh occurring on board 
ship. 

In the year 1853, a work entitled ''Naval Surgery, or Clinical Studies 
of the Surgical Diseases most commonly observed on Board of Ships of 
War, by Louis J. Saurel, D. M. M., &c.,"^ was published, and is referred 
to in the publisher's preface as the first edition of the present volume, 
which the author did not live to finish. Had he lived, it is probable he 
would have given us his views on the points which have been ably discussed 
in that part of the work for which we are indebted to Dr. Rochard. 

The summary of the lectures on the surgical service of the fleet, by Dr. 
Rochard, is valuable and suggestive. 

The military marine, he says, is created for combat. That is its chief 
mission, and to that end all the elements of its organization should tend. 
The care of the wounded in time of war is among the most important of 
the duties imposed upon naval surgeons, and is at the same time the most 
diflScult. Afloat, as well as ashore, war has exigencies before which every- 
thing must bend, and which often oppose insurmountable obstacles to the 
accomplishment of their functions. Then they need as much resignation 
as devotion, as much self-possession as experience, to rise to the height of 
their mission. 

The difficulties in the navy and the army are not the same. They consist 
chiefly, after a battle, in the number of wounded, the extent of ground over 
which they are scattered, and the insufficiency of the means of transportation ; 
in the navy, on the contrary, it is the crowding which embarrasses surgical 
service after a fight at sea. The position of the wounded sailor is better 
than that of the soldier. He has no apprehension of remaining in the rear 
and falling into the hands of the enemy; he is not obliged to submit to 
long hours of anguish, waiting for assistance; he is always sure of shelter, 
and, however murderous may be the contest, the number of surgeons and 
resources on board are almost always sufficient to meet all demands ; but 
these conditions, favourable as they are to the individual, are embarrassing 
for the service. On land the number of wounded never incommode mani- 
pulation ; afloat they necessarily trammel the surgeon's movements. In 
the narrow space into which so many men and so much material are 
crowded, the deficiency of space is a permanent difficulty. The combat, and 
the injuries caused by the fire of the enemy, always bring a certain amount 
of disorder, which is enhanced by the presence of the wounded. At all 
hazards they must be promptly removed from the batteries which they en- 
cumber. It is not a question of humanity only; their presence interferes 
with the manoeuvres of the artillery, and produces a depressing effect on 

' Chirurgie navale, ou etudes cTiniques sur les maladies chirurgicales que I'on 
observe le plus communement k bord des batiments de guerre, par Louis J. Saiirel, 
D. M. M., ex-chirurgien de 2e classe de la marine, membre de la Societe de Mede- 
cine-pratique de Montpellier, etc. 8vo. pp. 312. J. B. Balliere. Paris, 1853. 



1862.] 



Sal'rel and Roc hard, Xaval Surgery. 



151 



the moral tone of their comrades. Whatever may be their number, they 
should receive immediate care, and be put in a place of security, and on 
beds of some kind, until the end of the action. 

Three conditions are indispensable to attain this result : — 

1. An easy way and convenient means of transporting them to the hold 
or to the berth -deck. 

2. A sufficient space for urgent operations and first dressings. 

3. A locality sufficiently spacious to spread out mattresses to receive 
them afterwards. 

These conditions are readily obtained when the wounded are few, and 
succeed each other at long intervals ; but such cases are exceptional. When 
a fourth or a third of a crew. of from 600 to 1000 are wounded in the 
course of a few hours, as has happened, it is very different. 

The passing of wounded men below in sailing ships presents few difficul- 
ties. In single decked ships the hold is shallow, and there is not much 
space for the accommodation of wounded men during an action ; but vessels 
of this class are not, generally speaking, liable to have a large proportion 
of wounded. The large hatches of frigates and ships of the line facilitate 
the transportation of the wounded, and on the berth-deck and orlop there 
is usually abundant space for the spreading of mattresses. But in steamers 
it is different. Although the hatches are numerous, they are comparatively 
small. The engines and coal bunkers occupy so much space in the centre 
of the vessel, that it is very difficult to make suitable provision for the 
reception of wounded men in the hold. In illustration of these points 
there are given diagrams of the plans of the holds and berth-decks of the 
several classes of ships. 

Ships at anchor attacking fortresses suffer comparatively little. Of 
French frigates exposed to the fire of 116 pieces of cannon, distant four 
cables length from San Juan d'Ulloa, the Iphigenie had 5 killed and 30 
wounded, and the Tanger, Magador, and Sale suffered still less. At Pe- 
tropaulowski the frigate Forte had but 8 wounded. On the ITth October 
the French and English fleets before Sebastopol, at an average of seven 
cables length distance, sustained the fire of 316 pieces, most of them of 
large calibre, served by good gunners, for five hours, and at the end of the 
action, the 24 French ships, 12 of which were of the line, had 30 killed and 
181 wounded in all, and the English 44 killed and 266 wounded. 

Under such circumstances the wounded come at long intervals. Inasmuch 
as the batteries of one side only are engaged, the opposite affords space for 
the withdrawal of the wounded from the guns in action. 

When an engagement takes place under sail or steam, the batteries on 
both sides must be kept clear, and the wounded must be taken below at 
once: 

In the exercise at quarters in time of peace, it requires at least four 
minutes to pick up a man supposed to have been wounded near a gun, carry 
him to a hatch, secure him to a cot, and pass him below. Then the ship 
is tranquil, and every body preserves his self-possession. But it may be 
supposed that amidst the smoke, din, and confusion of battle, it would 
require a somewhat longer time to move a man seriously wounded. Now, 
if only 50 men are wounded, and allowing four minutes to transport each 
to the hold, three hours would be occupied in their transportation ; and 
during all this time the guns are encumbered and the gunners cannot ma- 
noeuvre their pieces without the chance of trampling upon their wounded 



152 



Reviews. 



[July 



comrades. And if the number should be increased throug-h the effects of 
the newly contrived explosive projectiles, the condition is worse. Hence, it 
seems indispensable that means should be devised of more rapidly removing 
so bloody a spectacle from view of the combatants. 

It is suggested that when it is probable a battle will be serious on board 
of a steamer, two passages from the deck below should be established for 
the wounded ; one forward, and another towards the stern of the vessel. 

As means of transportation, a cot or frame, fitted by ropes and blocks in 
a hatchway, so that it may be readily lowered with a wounded man strapped 
to it, is proposed, but objected to because of the difficulty of guarding it 
against extensive oscillations impressed upon it by the motions of the ship. 
A battle-chair, so arranged that it may be lowered by a pulley, is also sug- 
gested. But it is very questionable whether the arms of a strong man may 
not afford a better and more expeditious means of transporting a wounded 
man than any contrivance hitherto proposed. 

As in steamers, generally speaking, the engine divides the forward from 
the after part of the vessel, it becomes necessary, when two routes for the 
conveyance of the wounded are established, that the surgical force should 
be divided and posted at two points, the surgeon being at one and the 
senior assistant in charge of the other, both well supplied with the neces- 
sary instruments and appliances. 

A place for the deposit of wounded men during action is difficult to find 
in steamers. It is suggested, to meet the exigency, the bag-rack on the 
lower deck should be constructed of iron bars, so arranged that mattresses 
would be spread upon them, and then, on beating to quarters, the bags 
should be stowed in any empty coal bunker. 

Certain preliminary arrangements are to be made before battle. The 
distribution of tourniquets in the tops, required by an English regulation, 
may be dispensed with in steamers, for the reason that these vessels furl 
their sails before going into action, and very few, if any, men are kept aloft. 
But there should be garrots supplied to men at the guns. The writer of 
this notice submits that an efficient instrument consists of a piece of wood, 
five or six inches long, a half inch in diameter, turned with a slight rim at 
either end, near one of which is attached, by a clove-hitch, a piece of roller 
three feet and a half long, and two and a half inches wide, so that the stick 
may be about fifteen inches from one extremity, and, of course, twenty-seven 
from the other. This simple instrument is applied thus : the fillet is passed 
around the thigh, or arm, as the case may be, drawn tightly, and tied about 
six or seven inches from the stick ; the free ends, which are sufficiently long, 
are employed for securing the stick after it has been used in twisting the 
fillet to the degree of tightness necessary to arrest the hemorrhage. A fillet 
or ligature passed round a limb may be made tight enough to stop the flow 
of blood, by twisting with a stick ; but after this point is gained, one may 
be very much at loss for means of preventing the band from untwisting the 
instant the stick is abandoned ; the simple instrument just described, is 
proposed to obviate the difficulty on this point. 

Surgical dressings, &c., arranged in two boxes or trays, with suitable 
divisions, should be deposited in the dispensary, ready to be taken to each 
of the two appointed stations of the medical officers. 

Dr. Kochard gives, in a note, in detail, the quantities of various articles 
which raay be needed, on board of a ship of the line, whose complement is 
1087 nien. 



18C2.] 



Saurel and Ro c hard, Naval Surgery. 



153 



Dressings prepared, on a first-rate ship of the line, on the eve of 
battle : — 



Apparatus for amputations, in- 
cluding compresses, rollers, 
&c., in the same number. 

Bandages for fractures, differ- 
ent splints, graduated com- 
presses, &c. 



Bandages for the hand and foot. 



Bandages for the head. 



Bandages for the chest and 
shoulder. 



Bandages for the abdomen and 
pelvis. 



For the arm . 

" forearm 

" thigh five 
leg . 
Thigh . 
Leg 

Forearm . 
Bands for fingers 
Slings for the heel 
Splints for fingers 

Pads I^^M^'Jl^^f 

Bandages (Galen's) 
Triangles 
Chin-pieces 
Slings for the chin . 
Bandages for the body 
Scarfs or bands 
Cushions or pads for clavicle 
Spica bandages 
Triangular " 
Square for the groin 
Perineal or T . 
Suspensories . 



5 
10 

5 
10 
4 
8 
8 
48 
18 
18 



18 
18 
18 
24 
18 
4 
6 
12 
12 
12 
12 



For external use, cases not specified, rollers, compresses, &c., in sufficient 
quantities. Charpie opened, and in pledgets. Sponges. Waxed threads, 
single and double. Rolls of adhesive plaster. Strips of diachylon, of 
different sizes. Agaric. Resin, in powder, Garrots. Sharpened pins, 
for sutures. 

Each bandage is made in a separate parcel, and labelled ; those of the 
same kind being placed together, in a compartment of the box or tray. 

Ammonias liq. 



For internal use, bottles of 



Earthen vases of 



In addition to the above- 



Brandy. 
Camphorag tinctura. 
Ether, Chloroform. 
Ferri-persulphas. 
Laudanum, Vinegar. 
Plumbi acetas. 
Cerate. 
Olive oil. 



Plates and shells of tin 2 

Goblets .4 

Candles , . 2 

Bucket filled with sand 1 

Buckets " fresh water 2 

Brooms and swabs 2 

To these may be added two or three tin basins, and a half dozen towels. 

The surgeon should take care that the steward, nurses and other attend- 
ants are instructed, and that each one understands exactly the nature and 
extent of services required of him, so that at the moment of need the work 



154 



Reviews. 



[July 



may be executed in a neat, orderly manner without loss of time, or confu- 
sion of any kind. 

When the order is given to assemble at quarters the drum-beat gives the 
signal. 

On board Ficnch ships the first care is to evacuate the hospital, and have 
those patients who are confined to bed conveyed below, and those not capa- 
ble of performing duty at the guns are to be stationed in the hold to assist 
their wounded comrades, by supplying them with water to meet the demands 
of traumatic thirst, which is terrible in cases accompanied by great loss of 
blood. 

In sailing ships of the line, after the hospital has been cleared, the second 
and fourth surgeons, aided by the officers' servants, spread mattresses and 
covers proportioned in number to probable exigencies. The chief and third 
surgeons set up and arrange the operating table in the hold, and make sure 
that buckets of sand and fresh water and swabs are at hand. 

In steamers, the principal post occupied by the chief and third surgeons 
should contain the operating table, and instruments and dressings placed 
so as to be at hand. A weak mixture of wine and water in sufficient quan- 
tities, with goblets for the use of the wounded ; buckets of water, sand, and 
swabs should be provided, and everything secured against the motions of 
the ship. The chief surgeon should also take care that there is sufficient 
light supplied by lamps, lanterns, &c. 

The station of the second surgeon, at the opposite end of the ship, is to 
be provided and prepared in like manner. 

Having seen that all his orders have been executed, the chief surgeon 
then descends to his post, which he is not to leave, except by express order 
.of the commander of the ship. 

At the moment when firing is about to commence a profound calm reigns 
throughout the ship. Motionless expectation succeeds the tumult which 
immediately followed the drum-beat to quarters, and silence takes the place 
of noise. The moment is serious. Every one feels a necessity of collecting 
himself, and memory is busy with the past. The first broadside cuts short 
reflection, and every one thinks only of his duty. That of the surgeon is 
not the least painful. The emotions of the combat, and the excitement 
attending success, are equally unknown to him. He is ignorant of what is 
transpiring on deck. He judges of the greatness of the contest only by the 
horrors of its results ; he cannot conjecture the issue. Bent beneath the 
beams in his narrow retreat, where the want of air, space, and light are 
simultaneously experienced, seeking by doubtful illumination in a stifling 
atmosphere to extract a projectile or to cast a ligature about an open vessel ; 
sometimes overborne by the rapidity with which the wounded succeed each 
other, he must preserve, amidst the scene of carnage, the self-possession of 
the physician and the calm of the chief of his department. The execution 
of these austere duties is not always exempt from peril. Surgeons are 
classed as non-combatants in the division of the advantages which inure to 
success of the fight, though they do not always escape death. 

If, says Dr. Rochard, the navy should be called upon one day to renew 
the grand contests of past times, the means of destruction are now such as 
to equalize the chances of all, and where there is an equality of danger 
there should be an equality of glory. 

Operations requiring much time are rarely necessary during the engage- 
ment, and indeed it would be imprudent to attempt them. The surgeon's 



1862.] 



Saurel aod Rochard, Naval Surgery. 



155 



attention is to be given to urgent cases, and to the dressing of slight ones, 
that they may return to the deck. After the firing has ceased, he has to 
coDQplete his labours, attend carefully to every case, and arrange his hos- 
pital. 

The question of amputation under different circumstances of injury is 
judiciously discussed. He concludes that in compound and complicated 
fractures amputation should be the exception and not the rule of practice. 

If after a battle, while the decks are occupied by many wounded, bad 
weather should supervene, and require the closing of the ports, we may 
expect from humidity, and a vitiated atmosphere consequent upon reducing 
the means of ventilation, unfortunate complications. The danger augments 
with the number of wounded. To the ordinary causes of the vitiation of the 
atmosphere are added the emanations from extensive suppurating wounds, 
some of them complicated with gangrene. 

Deficiency of air, humidity, and miasms are three foes to the surgeon's 
efforts which must be guarded against. If the weather is fine and dry, and 
the ports can be kept open, there is little to fear ; ventilation takes care of 
itself, and guarantees salubrity. Under opposite circumstances precaution 
is indispensable, and sometimes no degree of care is enough to avert the 
danger. 

It is to be hoped that some system of ventilation for ships may be devised 
which will afford a ready means of furnishing abundant supplies of fresh air 
to the most profound and remote points of their structure. A forced ven- 
tilation in steamers ought not to be difficult to accomplish, and at a cost 
of very little power. In the absence of such contrivance, wind-sails and 
drying-stoves must be substituted. The former should be at every hatch, 
and fires in the latter should be constantly lighted and distributed at regular 
intervals among the beds; and beneath those from which the most ofi'ensive 
smells emanate broad vessels containing chloride of lime, slightly moistened, 
should be placed. 

The maintenance of an unexceptionable degree of cleanliness is most 
important ; but care should be taken that it be not attained at the cost of 
profuse and frequent washings. These should be proscribed when the 
weather is damp, or when the ports are closed. The broom and dry holy- 
stone should suffice for general cleaning, with the application of a domip 
swab to very dirty spots. And at all times hot fresh water, rendered 
slightly alkaline by an admixture of wood-ashes from the galley fires, is to 
be preferred while wounded men are on the decks. As a means of lessening 
the necessity of washing, canvas cloths might be spread between and around 
the beds during meals, for the purpose of receiving and removing imme- 
diately after, scraps of food dropped. 

Dressings should be renewed twice daily, and parts of apparatus should 
be changed whenever they become imbued with liquids discharged from 
wounds. Small pieces of dressings, charpie, &c., when removed, should be 
at once thrown overboard, and large bandages, compresses, &c., should be 
immersed in buckets of sea-water and speedily removed to the place desig- 
nated for washing them in fresh water. Wounds should remain exposed to 
the air no longer than is absolutely necessary to dress them. When the 
wounded are detained on board during a considerable period, whitewash, 
containing a little hypochlorite of lime, should be applied to the neighbour- 
ing wood-work from time to time. 

Do what we may, any considerable number of sick on the lower decks of 



156 



Reviews. 



[July 



a ship is never free from danger. The roost serious cases should be allocated 
in the most airy situations, and those capable of locomotion should be 
required to pass the greater part of the day on the spar deck, when the 
weather is favourable. Exposure to the open air, the vivifying influence 
of sunlight, sight of their comrades, and the change of scene produce the 
happiest effects upon their moral and physical condition, while their al)sence 
from the sick-quarters diminishes the crowding. On the other hand, in 
high latitudes, it may be necessary to send these cases to the berth-deck to 
shelter them from the cold, and from currents of chilling air. After the 
affair at Petropaulowski the French division went north, and four of the 
wounded, from the cold of the nights especially, w^ere attacked with tetanus 
and died. Xo cases occurred after the wounded were removed to the berth- 
deck. 

The diet of the w^ounded should receive particular attention. After a 
naval engagement the conditions in which they are placed are debilitating, 
and therefore a substantial and reparative regimen is the best calculated to 
protect them against threatened complications. 

A chapter is devoted to the consideration of the preparations necessary 
to be made by the medical officers who accompany boat expeditions and 
parties landing to attack strongholds on shore. There should be provided 
a strong tin case, covered with leather, of the dimensions and form of a 
knapsack, with drawers and compartments, to contain surgical instruments, 
some short splints, lint, sponges, rollers, adhesive plaster, simple cerate, 
thread, sewing needles, dressing pins, wax, sulphate of quinia divided into 
powders or pills, a glass cup, a tin or leather goblet, candle and candlestick, 
laudanum, ammonia, vinegar, tincture of camphor, brandy, &c. The 
liquids should be in strong glass bottles, each one packed in a separate 
drawer. This case may be strapped upon the back of an attendant who 
accompanies the march. The surgeon's position in the field may be marked 
by a yellow flag, and the hospital boat, or ship, as the extent of the expe- 
dition may suggest, may be designated in the same manner. 

It is w^ell to provide litters for the transportation of the wounded. Two 
shafts or poles, about the length of a boat-hook, ferruled at the extremities, 
one of which may be sharp, like a boarding-pike, and serve to repel enemies 
in case of need, having a piece of canvas, about six feet long and two and 
a half wide, fitted so that it may be attached to the poles by grummets, are 
readily converted into a litter, with the assistance of a couple of stretchers. 
In an extemporized litter of the kind a wounded man may be carried easily 
by four men, or even by two. If obtainable, the shafts may be made of 
stout bamboos, w^hich are strong and comparatively light. 

We have many valuable suggestions in this chapter, and interesting no- 
tices of several boat expeditions in which the French have been engaged or 
taken part. But enough has been said to indicate the nature and scope of 
the volume which we cheerfully commend to the younger medical officers of 
the navy. W. S. W. R. 



1862.] DoBELL, Germs and Yestiges of Disease. 15Y 



Art. XY. — Lecfinr^s on the Germs and Vestiges of Disease, and on the 
Prevention of the Invasion and Fatality of Disease by Periodical 
Examinations. Delivered at the Royal Intirmary for Diseases of the 
Chest. By Horace Dobell, M. D., &c. &c., Physician to the Infirmary. 
London: 1861. 8vo. pp. 198. 

A TRULY philosophical endeavour to analyze the facts of medical expe- 
rience should always be welcomed by the profession. It is no unwillingness 
to reason, or want of confidence in the value of careful ratiocination, that 
induces many of the best medical minds of the present time to rank them- 
selves, as therapeutists, under the banner of methodical empiricism. Not 
all going so far in opposition to rationalism as to believe with Trous- 
seau that this necessarily "ne conduit qu'a des sottises," they must, upon 
the very basis of induction, admit and honour all efforts towards the 
classification and generalization of medical facts. Of the results of such 
efforts, however, there has been a lamentable deficiency in the science and 
literature of practical medicine. The natural history of disease has been 
but vaguely studied, and taught according to routine and dogma. The 
want of a sound medical philosophy, or even philosophical method of study 
in medicine, is thus, to speak boldly, hardly better met than in the days of 
Celsus or Aretseus. We believe it to be impossible to apply at present, 
upon any extended scale, the recognized truths of physiology to the imme- 
diate purposes of the physician in the treatment of disease; but the biolo- 
gical or naturalistic method of investigation of the facts both of morbid 
or perturbed physiology, and of therapeutical experience, must be approved, 
and should be adopted. 

It is for the apparent honesty of his effort in this direction, quite as much 
as for the degree of his success therein, that the work of Dr. Dobell appears 
to us to be entitled to very attentive and respectful consideration. His 
subject is one which must interest every thoughtful physician. The occa- 
sion of its having occupied his mind so far as to lead to the preparation of 
this work, may be best understood from his own statement : — 

" "When I commenced private practice, I had devoted more time to the study 
of medicine in hospitals and medical schools than most students have at their 
disposal; in addition to which I had read nearly every medical and surgical 
work of good repute, ancient and modern. And I naturally expected to find 
myself quite at home with any cases which might present themselves in private 
practice. To my surprise and disappointment, however, I found myself sur- 
rounded by complaints which appeared quite strange to me, and I kept vainly 
hoping that each new case might he placed under one of the well-known head- 
ing so familiar to me in the hospital-ward, the out-patient room, the book, or the 
lecture theatre, and the management of which I had so carefully learnt. 

" Cases of pneumonia, apoplexy, variola, fever, or the like, were positively 
refreshing, when, from time to time, they came in their well-known features. But 
these were few and far between ; whereas I found the principal part of my time 
occupied with diseases or states of health for which I could find no special 
names, and for which I had learnt no plans of treatment." 

"Many years after the period to which I refer, an article appeared in the 
Times newspaper, just at the time that I was engaged in making notes for these 
lectures, which appeared to be so apposite that I placed it with my notes, as full 
of interest and meaning." 



158 



PvEYIEWS. 



[July 



The following is part of the article referred to : — 

"What is it that is worse than a sweatino; sickness, or a plague, which comes 
with a bale of Turkish goods, and goes with a great fire, which wears itself out, 
and leaves no record but in story, which old men may describe to wondering 
grandchildren, and which doctors may now set down as an individual and extinct 
type-of disease? It is not disease, hut it is not health. It is a low state of vitality, 
of physical power, of mental energy, of eDj'oyment. and even of moral strength. 
.... Shocking as it may seem, a plague once in twenty years seems but a light 
evil to so low a condition of humanity." 

" These remarks are directed chiefly to the very poor : but it is not they alone 
who suffer from states of health here so forcibly portrayed. Many of the con- 
ditions of low health, and of anomalous disease to which I have referred, are more 
frequent among the well-oflF than among the poor." (pp. 30-32.) 

The plan of the author involves a scrutiny of the very foundations of the 
theory and practice of medicine. His first lecture opens with the announce- 
ment of a medical creed, in the following terms : 1, That man may be the 
instrument through whom the invasion and progress of premature destruc- 
tive changes in the human organism may be prevented or arrested. 2. That 
man may be the instrument through whom the damaged organism may be 
more efficiently repaired. 3. That man may be the instrument through 
whom the sufferings of the human being may be alleviated. The justifica- 
tion of medical practice requiring a belief in these articles, it is rightly 
considered that their truth should be first well established as the basis of 
any system of therapeutical doctrine. 

The third article is too familiarly attested to need much remark. The 
first and second, concerning the aid man may give in promoting the repair 
or preventing the destruction of the organism, must be considered in view 
of the results of investigation of the capacity of the organisrn itaelf to 
effect these ends icithout the instrumentaiity of man. This investigation 
must be prior, in a logical sense at least, to therapeutical experimentation. 
Dr. Dobell, therefore, gives it his first attention ; occupying with it the 
whole of the first two lectures. 

Facts in comparative physiology are brought to bear upon the laws of 
production, repair, and reproduction of the human organism. The greater 
portion of these facts is collected by our author in an appendix ; where the 
reader may study at length numerous examples, from all divisions of the 
animal kingdom, of spontaneous recuperative power. 

The general law which the author thinks himself justified in inditcing 
from these well authenticated examples, is thus expressed: "At every period 
of an animal's life, the force manifested in production, maintenance, growth 
and repair, and reproduction, is sufficient in every respect, and determined 
in that direction, essential at the time to the attainment of the ultimatum.''^ 
The term ultimatum here means merely the consummation of the design 
with which the animal appears to have been formed. In the insect, neither 
the larva nor the pupa has attained the ultimatum ; nor can the imago be 
considered to have done so, until it has secured the multiplication of the 
species, in the fecundation of the necessary number of ova. In man, the 
ultimatum of existence is not bounded by the same limitation, but includes 
still higher functions. 

The point of especial interest in the application of this law is the deter- 
mination of force at each epoch of the animal's career, in that direction 
essential at the time to the attainment of the ultimatum. The individual 
is, however, throughout the animal kingdom, subservient to the species; 
and our idea of the ultimatum must be extended to the species. If the 



1862.] 



DoBELL, Germs and Yestiges of Disease. 



159 



career of an individual of any species be cut short, it does not necessarily 
follow that the law for the attainment of the ultimatum has been violated. 

The determination of reproductive and reparative force to the restoration 
of that part the permanence of which at a particular time is a condition 
of the animal's existence, and which is, by the circumstances of its life at 
that time, most subject to injury, is beautifully illustrated in Hydriformia, 
Asteriae, and Cirripedia. Dr. Dobell quotes the following from Darwin : — 

"In cirripeds, the larvge in the first stage have three pairs of legs, a very sim- 
ple single eye, and a probosciformed mouth, with which they feed largely, for 
they increase much in size. In the second stage, answering to the chrysalis 
stage of butterflies, they have six pairs of beautifully constructed natatory legs, 
a pair of magnificent compound eyes, and extremely complex antennae, but they 
have a closed and imperfect mouth and cannot feed; their function at this stage 
is to search by their well-developed organs of sense, and to reach by their active 
powers of swimming, a proper place on which to become attached and to un- 
dergo their final metamorphosis. When this is completed they are fixed for 
life. Their legs are now converted into prehensile organs, they again obtain a 
well-constructed mouth, but they have no antennae, and their two eyes are now 
converted into a minute, single, and very simple eye-spot." 

Among vertebrated animals, the power of reproducing lost limbs is be- 
stowed most largely upon the salamander, an animal of predatory habits, 
and living among carnivorous feeders. In the land lizard, the tail is at 
once a means by which it is apt to be captured, and its instrument in eluding 
its pursuers; and a power to disengage it from itself is coupled with an 
extraordinary facility in reproducing the lost part. The fish requires the 
persistence of the fins as a condition of its existence, and they are pecu- 
liarly exposed to injury, from constant use and from the attacks of enemies; 
the power of repair is, accordingly, especially determined to them. 

Now, what, in man, is the special direction in which reproductive and 
reparative energy is determined? After birth, at least, there is no instance 
on record of even an attempt at the restoration of a lost human limb ; 
although supernumerary fingers have sometimes been reproduced after re- 
moval. But Dr. Dobell insists that this non-reproduction of limbs comes 
from no want of the force necessary to restore them, if it were a condition 
of our existence that they should be so reproduced. The occasional re- 
formation of a whole bone, and the cases reported by Dr. Simpson of the 
renewal, although imperfect, of limbs spontaneously amputated in the foetus 
in utero, testify to the. existence of this capacity, latent, as it were, in the 
higher vertebrata. 

The study of the conditions of existence of the highest animals, will 
inform us of the direction in which reproductive energy is exhibited in them. 
As -we ascend the scale, we find most remarkable advances in the develop- 
ment of intelligence, and in the complexity and delicacy with which organs 
are correlated. By reason of the former, man is much less dependent than 
the lower animals upon the possession of his external members. 

With increased complexity and delicacy in the correlation of organs, 
comes a proportionate increase in the importance and difficulty of keeping 
them repaired. The influence of a highly and delicately organized nervous 
apparatus upon susceptibility to disease is illustrated to some extent even 
in the domestic animals; although much more largely in man. 

It may be properly urged, then, that in man, a continual reproduction is 
going on, of those parts most necessary to the conditions of his existence, 
or "the necessities of the ultimatum." This is seen in the formation and 
re-formation of blood-corpuscles, of the secreting cells of glands, and of 



160 



Reyietts. 



[July 



cuticular epithelium. The alterations in the size and activity of blood- 
vessels following upon obstruction or injury; the increase in the number of 
fibres of the muscular tissue of the heart or bladder when extraordinary 
resistance is to be surmounted; the occurrence of vicarious secretion, and 
other examples, are dilated upon by our author, as showing how the vital 
energy in man is especially determined towards the presermtion of cam- 
pleteness in the complex correlations of his organism, amidst the no less 
complicated dangei's by which it is surrounded. Paget is quoted as con- 
firming this view by the statement given by him of the limits of reproduc- 
tive powder in man and other mammalia. These include only "the blood 
and epithelium," "the gelatinous tissues, cellular and tendinous tissues and 
bones," and "those which are inserted in other tissues, not as essential to 
their structure, but as accessories, as connecting or incorporating them with 
the other structures of vegetative or animal life; such as nerve-fibres and 
bloodvessels." All of these are important to those correlations of organs 
which have been alluded to. As Dr. Dobell remarks, the organs which 
cannot be so perfectly restored are either such as are seldom entirely removed 
without the death of the individual, or such as are provided with duplicates 
endowed with the power to assume a complemental function, or such as are 
competent in themselves to compensate for loss of a part by augmenting 
the functions of the remainder. 

Beyond this, however, the human organism is also subjected to dangers 
other than those included in solutions of continuity ; hj poisons, organic 
and inorganic, and by the whole army of influences commonly classed as 
causes of disease. To what extent, it becomes necessary to ask, is the 
animal body capable of preventing the invasion and resisting the pi'ogress 
of premature destructive changes, without the intervention of man? The 
simplest example of this is afforded in the introduction of an inorganic 
poison, as arsenic. 

Arsenic and other poisons are disposed of, so as not to be injurious, as 
we know that a poisonous dose may be given with impunity, if divided into 
several parts and given at certain intervals. How, and within what limits, 
then, is it, that the organism disposes of poisons, for its protection against 
their power ? 

This forms the first subject of Dr. DobelPs second lecture. The method 
of disposal of poisons introduced into the economy is best understood by 
reference to the normal excretory processes. These remove substances 
which, if remaining, would prove essentially poisonous. Dr. Richardson 
has illustrated this in his experiments upon the injection of lactic acid into 
the peritoneal cavity of animals. The balance of excretion and secretion, 
with nutrition, is indispensable to health. 

"When, however, this balance is disturbed, some matter essential to the con- 
stitution of some other matter becomes deficient, or some matter collects in 
undue quantity, and, in either case, other organs and functions than those prima- 
rily involved are drawn into the service of the organism, to restore, if possible, 
the balance thus disturbed. And when we bear in mind the important fact that 
the normal constitution of any one part is dependent on the normal constitution 
of all the rest, w^e shall at once see how easily imperfectly formed elements of 
nutrition may be generated in the organism, with all the features which we are 
accustomed to recognize as disease. How complicated may the processes 
become! How complex the outward manifestations! Or, again, how simple ! 
For all -that may attract the physician's observation may be tlie last scene, suc- 
cessful or unsuccessful, in the attempt to get rid of a redundance or to supply a 
want." (p. 25.) 



1862.] 



DoBELL, Germs and Vestiges of Disease. 



161 



As to the limits within which vital energy, or, as our author prefers to 
call it, the "vitalized mode of force," can act successfully in asTesting the 
destruction of the organism, no rule can be definitely laid down which will 
apply to individuals. It must be admitted that the human being may, un- 
aided, live through injury, through disease, through almost anything, under 
favourable circumstances. 

These last three words confer, or constitute, to use our own words, the 
physician's license to practice. How seldom are the circumstances abso- 
lutely and perfectly favourable ! If they were, our vocation would indeed 
be a sinecure. Not being so, the manifold and most important influences 
of circumstances upon the manifestations of vital energy must be carefully 
studied, to afford answers to the great although simple questions, what is 
there for the medical practitioner to do, and how ought he to do it? 

Dr. Dobell asserts here the very important proposition, "that the vital- 
ized mode of force may be altered in its attributes of quantity and quality 
by numerous causes." This involves a discussion, succinctly gone into by 
the author, of the doctrine of force, and the correlation of physical and vital 
forces, as modes of motion, expounded by Grove, Carpenter, and others. As 
all the knowledge we have of different modes of force is inseparably con- 
nected with different modes of matter, it is concluded that the "necessary 
concurrent modes of matter" are, as regards force, the "conditions of its 
existence." Changes in the modes of matter connected with vital force 
must subject it to changes in its attributes or manifestations. 

The view maintained by so many physiologists, that the amount of vital 
force with which each individual organism is endowed is a limited quantity, 
a portion of which is "expended" in development, growth, and maintenance, 
so that "reparative power bears an inverse ratio to the amount of force 
already consumed in these processes," is contradicted by our author. Let 
us give his ground of opposition to it the benefit of his own statement. 

"According to the most recent statistics employed by actuaries, it may be 
calculated, that out of every 100,000 children bom. only 63,296 reach the age 
of twenty-five years ; 36,704 dying from various causes before that age. If each 
of these 63,296 individuals has, at the age of twenty-five, produced one child aud 
y\ths, the number thus obtained will be only a fraction more than is sufficient 
to compensate for loss, and to bring the population up to the original quantity. 
In order, then, to keep up the population, the vitalized mode of force with which 
each individual was endowed at birth must have accumulated at least y'^tus 
during life, instead of wasting, expending, or being consumed ; otherwise,"the 
individuals of each successive generation would be endowed with a smaller quan- 
tity of force than their predecessors. And as, so far from the population being 
only maintained at a fixed quantity, it increases at a great rate, the accumulation 
of vital mode of force must be proportionably great, to fulfil this necessity of 
org'a-nic existence, we discern — or at least such is my hypothesis — that every 
living thing is given, 1st, a certain endoioment of vitalized mode of force, with 
which to begin its career ; 2dly, accumidators of fresh force, the amount which 
it can thus accumulate being regulated only, c ceteris paribus, hj the require- 
ments of the ultimatum." (p. 42.) 

No question in biology is more interesting, aud perhaps none more ex- 
tensive in its bearings, than that which is thus opened before us. It would 
be quite impossible to do justice to its consideration within our limits. We 
must say, however, that the hypothesis abovestated appears to us tobeentirely 
gratuitous. It may be readily granted that there is no evidence anywhere 
of the annihilation of force, any more than of matter ; that what is, or 
should be, meant by such expressions as loss, expenditure, or consumption 
No. LXXXYIL— July 1862. 11 



162 



Reviews. 



[July 



of force, is merely the determination of force into other modes or directions* 
i. e., its conversion or devolution into other kinds of force. But, in this 
sense, we know that there is a limitation to every special impulse in the 
dynamics of nature. We know that all terrestrial life, in each individual, 
tends to certain death, at or near a definite period. "We believe that the 
only ascertained accumulator of vital energy belongs not to the individual, 
but more properly to the species ; being the conjugation of the sexes, the 
union of the sperm-cell and the germ-cell. This view requires the admis- 
sion of the truth of Carpenter's assertion, that ''between generation and 
development (including budding) there would seem to be a kind of anta- 
gonism. Whilst every act of development tends to diminish the germinal 
capacity, the act of generation renews it." 

But this does not prevent the conditions of life, or "concurrent modes of 
matter," from exerting a marked influence upon reproduction and its results, 
as well as upon individual vital energy. Dr. Dobell's hypothesis is not 
necessary to his own conclusions. He remarks, very truly, that Darwin has 
not, in putting forward his theory of "natural selection," done full justice 
to the "conditions of existence," as affecting both the individual and the 
species. There is no difficulty in assenting to our author's conclusions upon 
the subject at which we have been glancing, as follows : — 

"That the vitalized mode of force may be altered in quantity and quality by 
numerous causes. 

"That these causes may affect either the existing individual, a succeeding 
generation, or both. 

"That these causes are, prindpalli/, the vestiges of disease, existing or coeta- 
neons diseases, and the conditions of life.'' 

"The effects of injury or disease and the manifestation of the vitalized mode 
of force in protecting, restoring, or repairing the organism, depend upon the 
relation which exists at the time between the following conditions : — 

"a. The position of the animal and of the part affected, at the time, with 
respect to ttie attainment of the ultimatum. 

",3. The state of the part affected, and of all correlated parts. 

"y. The state of the conditions of life at the time. 

"§. The quantitative and qualitative state of the vitalized mode of force." 
(pp. 47-8.) 

We are thus brought to the more practical part of the volume; which 
introduces the study of the vestiges and germs, or the "wells and springs" 
of disease, by an animated account of "a day's practice." A number of 
chronic cases, and a few acute ones, are described, to illustrate the connec- 
tion of the occurrence, severity and mortality of diseases with the previous 
medical and hygienic biography of the individual. Here we begin to be 
somewhat painfully reminded of the great gulfs of difficulty which pathology 
presents, and which no theor}^, or, so far, induction has been able to bridge 
over with other than merely temporary structures. The first case, very 
graphically narrated, is one of nervous disorder; in which the diagnosis is 
nmde, that the patient is "saturated with the poison of rheumatism." The 
second is that of a corpulent old lady, "teazed to death with erysipelas," 
or rather eczema, of the ears and sides of the head, with other complaints. 
A strict examination leads to the "discovery that she is saturated with the 
poison of gout, or rheumatism, most probably gout, which is acting as the 
germ of several forms of disease." 

Now,, what is rheumatism, and what is gout? And what is that poison, 
or what are those poisons, with which these patients were saturated? How 
that most probably^ ^ interferes with the eqiianimity of our self-gratulating 



1862.] 



Dob ELL, Germs and Yestiges of Disease. 



163 



inductive medical philosophy! Probably enough, the diagnosis may be 
correct; although it does not follow so necessarily from the symptoms 
related as our author's confident expressions might seem to indicate. And, 
with gv%2it prohahility, we may believe that, in the one case, the poison is 
lactic, and in the other uric acid. But a doubt remains, which is of serious 
moment to our ratio medendi. 

It would be extremely difficult to do justice, in a few words, to the re- 
mainder of Dr. Dobell's work, which has been carefully thought out, and 
closely written, so as scarcely to bear further condensation. We commend 
it to the study of the reader, as containing suggestions, and evolving prin- 
ciples, which, however they may have been before presented, are here elabo- 
rated, in a manner well adapted to favour their proper appreciation. The 
immediate purpose of the remaining lectures is to show how the vestiges 
of one disease become, in very many cases, the essential antecedents, the 
predisposing antecedents, or the causes of fatality, in other diseases. This 
is done by a careful and tabulated etiological analysis of typhus and typhoid 
fever, apoplexy, paralysis, heart disease, pericarditis, rheumatism, gout, 
bronchitis, atrophy, and debility. The statistics of the Registrar-General's 
reports are skilfully made nse of, and the very extensive and important 
interdependence of diseases is satisfactorily demonstrated. A similar exhi- 
bition is then made of the importance of anaemia, of syphilis, and of fatty 
degeneration, as vestiges, and as frequently unrecognized germs of disease, 
and causes of deaths registered under quite different names. 

A single example of the first of these series of analyses may suffice to 
illustrate their nature. 



Vestiges of one or more attacks 
OF Gout. 


Predisposing antece- 
dents to. 


Essential antece- 
dents to. 


Causes op fatalitt 

IN. 


Deposits of urate of soda in 
and about joints and some 
other parts. 

Tendency to a return of the 
attack in the parts pre- 
viously affected. 

Anaemia and nervous ex- 
haustion, especially from 
repeated attacks. 


Apoplexy. 

Attacks of Gout. 

Bronchitis, rheum- 
atic and gouty at- 
tacks, typhus. 


Heart diseases. 

Atrophy and de- 
bility, and do. 
in offspring. 


Bronchitis, rheu- 
matism & gout, 
typhus, heart 
disease. 



The following passage from Dr. Dobell's last chapter will convey very 
succinctly his conclusions, and his view of their practical bearing: — 

"We have plainly seen that the organism is competent to take care of itself, 
provided that it possesses a normal vital energy, ' and is surrounded by normal 
conditions of life ; and we have also seen that the great causes of defect in the 
vital energy are, the vestiges of disease and abnormal conditions of life ; and 
we have also learned that the diseases, from which the vestiges result, are invited, 
by defects of the vital energy ; and that when thus invited and received into 
the organism, they are capable of being disposed of without leaving vestiges 
behind, if the vital energy is free from excessive defect ; that thus these vestiges 
are due to defective vital energy. And as we have learned that the earliest 
invasion of defects in the vital energy, upon which all the long and intricate 
succession of ills depend as their germ — as we have learned, I say, that this 
state of germination exists at a period anterior to the manifestation of disease 



Designated in the work by the symbol V. M. F., or ^'vitalized mode of force.^'' 



164 



Reviews. 



[July 



in its ordinary characters, and that it is to be found in the garb of slight impair- 
ments of the general health, the indications of which are more and more evasive 
and occult, the earlier the stage of germination ; and, finally, as we have learned 
that it is in this occult and evasive stage of germination that the defect is most 
easily and most efficiently to he remedied ; I think you will agree with me in the 
practical conclusion at which I have arrived. 

" That the manner in which man is to exercise his instrumentality for the pre- 
vention of disease, the prevention of the vestiges of disease, and the prevention 
of fatality in disease, is to search out these earliest evasive periods of defect in 
the physiological state, and to adopt measures for their remedy. This appears 
to me to be the highest, the most ennobled duty of the physician, calling for the 
most abstruse knowledge of the science of life, the deepest experience in disease, 
the keenest exercise of the perceptive faculties, the calmest, most far-sighted 
reasoning, and the wisest judgment — a duty as much above the management of 
acute disease as to rule an empire is above fighting a pitched battle." (p. 153.) 

Dr. Dobell then proposes to anticipate, in individual cases, the develop- 
ment or germination of morbid conditions, by instituting, as a custom, a 
system of periodical examination, to tvhich all persons should submit 
themselves, and to which they should submit their children. Having no 
occasion to doubt that this would be an immense benefit to the public, a 
little more consideration is necessary to enable us to see how it would affect 
the profession. 

In order to maintain the interests of medical men, however, under such 
a system, it would only require to establish such a scale of remuneration 
for these thorough scientific examinations, as would correspond with their 
value to patients in economy of health and in lessening the probable need 
of much intermediate attendance. Of course, the poor should be provided 
for in this arrangement, by the formation of special departments in all hos- 
pitals or dispensaries, for the purpose; whereby, as our author urges, a 
great saving of medicine, now expended in mere temporary relief, might 
be attained. 

We believe that this project, novel as it may seem, affords much pro- 
bability of usefulness. The difficulty of securing its general introduction 
will, it is likely, be greater with those who are most to be benefited, 
namely, the public at large, than with physicians. Many, who are ex- 
cessively anxious about obvious symptoms of disease, prefer to remain 
obstinately blind to remote dangers or latent evils. It may be very hard 
to convince these of the value of a preventive examination while they are 
in tolerable health, or to persuade them to the use of precautions, however 
timely, which may involve some trouble or self-denial. On the other hand, 
the medical man, too often tantalized by uncertainties of prognosis, and 
difficulties of treatment, growing out of the "defective vital energy" and 
"conditions of life" of his patients, may be gratified to find opportunities 
for the exercise of his skill and judgment, where certain and favourable 
results may be almost calculated upon, and where death is not continually 
knocking at the door. The proposal of Dr. Dobell, then, even if it should 
not meet with immediate acceptance, is one of so reasonable a character, 
as to deserve consideration. The thanks of the profession are due, more- 
over, to its author, for a work, so full of careful and laborious thought, 
based directly upon assiduous observation, as to constitute an important 
contribution to scientific medicine. H. H. 



1862.] 



165 



BIBLIOGRAPHICAL NOTICES. 

Art. XYI. — Reports of American Institutions for the Insane. 

1. Of the Butler Hospital, for the year 1860. 

2. Of the New Jersey State Hospital, for the year 1860. 

3. Of the Western Asylum of Virginia, for the fiscal year 1859-60. 

4. Of the State Asylum of South Carolina, for the year 1860. 

5. Of the Northern Ohio Asylum, for the fiscal year 1859-60. 

6. Of the Hamilton County [Ohio) Asylum, for the fiscal year 1858-59. 

7. Of the Asylum of California, for the year 1858. 

8. Of the Wisconsin State Hospital, for the year 1860. 

1. The principal numerical records of the Butler Hospital for the year 1860, 
are as follows : — 

Men. Women. Total. 

Patients at the beginning of the year . .68 67 135 

Admitted in course of the year . . . .33 25 58 

Whole number 101 92 193 

Discharged, including deaths .... 33 33 66 

Remaining at the end of the year ... 68 59 127 

Of those discharged, there were cured . . 22 

Died . 15 

" The deaths include but two cases of recent attack. The rest were of per- 
sons who had been insane for a considerable period. Among them were four 
women, aged, respectively, 71, 77, 78, and 93." 

The publication before us contains one of those interesting monographic 
essays for which the reports of Dr. Ray have become remarkable. The subject 
treated is, as nearly as can well be expressed, the suppression of a hereditary 
tendency to insanity. We shall attempt, by a great abridgment from the ori- 
ginal, to impart a general view of the whole essay. 

" The hereditary character of insanity is a fact as firmly established as that 
of the propagation of certain other diseases by contagion. And, unquestiona- 
bly, of all the agencies concerned in the production of insanity, this is the most 
prolific. ^ * 

• " The organic law in question does not imply the transmission of actual dis- 
ease, but of tendencies to disease ; nor is it always in the line of direct descent, 
nor with any regulated degree of intensity. It may skip over, so to speak, a 
whole generation, and make its appearance in the next. It maybe traced back 
to its source, not through parents, but through uncles and aunts. It may be 
overt and unmistakable insanity in the child, and eccentricity or strong pecu- 
liarity in the parent ; and vice versa. The tendency may be transmitted irre- 
spective of other parental qualities ; and the child who bears the features 
exclusively of the father, may inherit the mother's tendency to disease. It may 
strike down its victim in the freshness and vigour of youth ; it may wait until 
the mind has stood many a shock, and encountered many a trial. 

The case, however, is one of not unmingled discouragement. Here, as 
everywhere else, nature mitigates the severity of its laws by compensatory 
arrangements. The organic condition on which the tendency depends is not 
invariably transmitted to every child, any more than certain traits of body or 
mind ; or, if transmitted, is endued with so little activity and power as to 
remain dormant, and become extinguished in the next generation by the over- 
powering tendencies of a different blood. And even when transmitted in a state 
of considerable energy, it may often be kept in abeyance by a course of bodily 



166 



Bibliographical IN'otices. 



[July 



and mental discipline specially ordered for this purpose. * * * There is 
reason to believe that many persons, thus unhappily constituted, have warded 
off an attack of disease, by looliin^ the evil firmly in the face, and resolutely 
shunning, in their diet, regimen, habits, occupations and amusements, mental 
and bodily exercises of every description, whatever might be supposed likely to 
produce unhealthy excitement. 

" The first consideration I would urge on this class of persons, is, that a ten- 
dency to mental disease is liable to be increased by any derangement of the 
bodily health. * * * Parents who have reason to fear the existence of here- 
ditary mental infirmities in their offspring, have an additional inducement to 
watch over their health, to strengthen their bodily powers, and promote a happy 
balance of the various faculties of the mind. * * 

"Although insanity seldom makes its appearance in childhood, yet it can 
hardly be doubted that the initiatory step is often taken at this period towards 
the development of morbid tendencies. * * In the physical education of 
this description of children, it should be a prominent object to strengthen the 
nervous system. ^ * ^ Much sedentary employment, much confinement 
to warm rooms, sleeping on feathers — all improper enough under any circum- 
stances — are peculiarly adapted to foster susceptibilities to nervous disease. 
^ ^ ^ On the other hand, considerable exercise in the open air. with some 
disregard of atmospherical conditions, serves to expend the surplus nervous 
energies, and thus excite a healthier activity in the nervous system. Upon no 
class of children does the hot-house management operate more unfavourably 
than on that we are here considering. Upon no other class of children do 
labour and exposure, properly regulated, prove more salutary; and parents 
cannot make a greater nriistake than to lavish upon them the tenderest nursing. 

" Of more importance, however, than all this, is the mental and moral training 
— or. more strictly speaking, the education and exercise of the brain. This 
must be managed with paramount reference to its health, to which every other 
consideration should be subservient. This, of course, requires prudence and 
discretion, a disregard of the more attractive objects of education, and a supe- 
riority over the vulgar prejudices so prevalent on this subject. Whatever 
habits or exercises are calculated to impair the mental health of any child must 
necessarily favour the growth of morbid tendencies wherever they exist. Errors 
which may be harmless to such as are happily organized, act with fearful effect 
upon those who have inherited a proclivity to disease. The most pernicious, 
and, at the same time, the most common of these errors in our present methods 
of education, is to require an excessive amount of study. It is curious how few 
have any other idea of the youthful brain, than that of a machine exempted 
from the ordinary lot of wear and tear. * * * 

" Children are made to study while yet too young. * * * But it is at a 
later period, when the common repugnance to study is overcome by its glittering 
rewards, that the danger begins. By one motive or another, the brain is stimu- 
lated to an amount of application that would be excessive in adult age. The 
requirements of teachers, the love of distinction, the thirst for knowledge, blunt 
the sense of fatigue, and the usual ignorance or carelessness of nature's laws 
utters no warning against the danger. Six. eight, ten hours a day, in school or 
out, the mind is engaged in the most exhaustive exercise, and even the night is 
not entirely given to rest. If anything is calculated to foster unhealthy tenden- 
cies, it certainly is such management as this, because it vitiates and weakens 
those energies on which we must chiefly rely in maintaining the health of the 
brain against the influence of abnormal tendencies. 

" Supposing the individual who has inherited tendencies to mental disease, to 

have arrived at manhood and entered on the serious business of life, how shall 

he prevent, if possible, the development of those tendencies into actual disease. 
* * 

" The necessity of ordering one's life with reference to this constitutional 
defect being admitted, it must be premised that the same rules of living are not 
equally 'applicable to all men. Difference of temperament, of education, of 
taste, of pursuits, require diversity of management ; insomuch that a course of 
living most salutary to one might be tilled with danger to another. * ^ * 



1862.] 



American Insane Hospital Eeports, 



167 



"Most persons have some weak point in their physical constitution, and this, 
by a well-known law of the animal economy, is the first to suffer under any 
general disturbance of the vital actions. AVhatever habit or indulgence, there- 
fore, may be supposed, under the common rules of hygiene, to impair the vital 
energies, should be carefully shunned. Good habits of living, abundant exercise 
in the open air, unstinted sleep, plain, nutritious food, moderation and tempe- 
rance in all things, beneficial as they are to all. are peculiarly important to those 
whose hereditary tendencies expose them to mental disease. Especially are 
stimulants, and whatever else is calculated to affect the nervous system, to be 
used with extreme caution. I do not say that they are invariably and uncondi- 
tionally injurious, but that they generally are when used to excess, and often 
are, even when used with judicious moderation. Nobody, therefore, with the 
morbid tendencies in question, and sincerely desirous of preventing their devel- 
opment, will hesitate to deny himself all indulgence in tobacco and spirituous 
liquors, not implicitly required by some other conditions. * * ^ 

" Excessive bodily exertion, by deranging some of the functions of organic 
life, may thus indirectly occasion mental disease, and therefore should be cau- 
tiously used by the class of persons in question. No small amount of insanity 
in this country, especially among the young married American women of the 
humbler classes, is produced by a dea-ree of daily toil greatly beyond their power 
of endurance, and enlivened by insufficient recreation or amusement. ^ * * 

" However important may be the physical regimen of persons predisposed to 
mental disease, it is. unquestionably, upon their mental exercises that the fate 
of the larger portion must chiefly depend. How these shall be ordered so as 
to best secure the object in view — what kind and amount of mental application 
shall be allowed — what moral and intellectual powers shall be cultivated or 
neglected — these are Cjuestions to be carefully and intelligently considered. * * 

•'By the class of persons whose case we are here considering, no more con- 
servative agency can be had than that of suitable and steady employment. ^ * 

'•It should require an amount of application much less than that deemed safe 
and proper in more happily constituted minds. Here the brain is peculiarly 
sensitive to any strain upon its energies, and being deprived of its proper elas- 
ticity, it fails to recover itself completely when the tension is removed. A 
degree of irritability, and perhaps of discomfort, is finally established, which 
may be readily converted into disease. A full amount of mental labour, there- 
fore, is out of the C|uestion. and it is the part of wisdom to recognize the fact 
and conform to its requisitions. 

The employment should be not merely an easy sort of drudgery or busy 
idleness, bat one as interesting and useful as practicable, and adapted to the 
person's taste and station. Simple occupation of the attention is better than 
nothing, but it lacks those conservative influences which flow from the con- 
sciousness of having accomplished something that needed to be done. It should 
involve no great responsibility, nor subject one to unpleasant intercourse with 
others. * * * 

"From social pleasures of the simple, cpiiet kind, the happiest effect may be 
expected; but absolute seclusion should not be more carefully avoided than 
gatherings of people where the sound of passion is heard, and the heart and the 
will are carried away captive by the irresistible power of sympathy. ^ * 

Of any employment or recreation, it should be an indispensable condition 
that it should not curtail the proper allowance of sleep, either by encroaching 
on its regular hours, or by filling the mind with thoughts and images that refuse 
to depart at bidding. Deficient sleep is a source of imminent peril, and when 
it continues for several days, the appropriate remedies should be sought without 
delay. * * ^ 

" When the morbid tendency begins to show itself, merely in unusual restless- 
ness, there may be a craving for amusements and exciting scenes, which friends 
are too ready to indulge, with no idea of the danger they incur. Nothing can 
be more mischievous than such indulgence, calculated, as it is. to cherish the 
kindling spark and fan it into an uncontrollable flame. ^ ^ 

" Persons predisposed to mental disease should carefully avoid a partial, one- 
sided cultivation of their mental powers — a fault to which their mental const!- 



168 



Bibliographical Notices. 



[July 



tution renders them peculiarly liable. Let them bear in mind th-at every promi- 
nent trait of character, intellectual or moral, every favourite form of mental 
exercise is liable to be fostered at the expense of other exercises and attributes, 
until it becomes an indication of actual disease. Here lies their peculiar danger, 
that the very thing most agreeable to their taste and feelings, is that which they 
have most to fear. Many of this class of persons possess a large endowment of 
the ideal faculty. They delight to dwell in the regions of fancy, and the subjects 
they habitually contemplate are such as the imagination only can supply. * * * 
Such persons should beware how they yield to their favourite contemplations. 
As a matter of safety, they should cultivate those faculties which are concerned 
with objective or definite truths, such as those of mathematics, natural history, 
and natural philosophy. These require a more equal and steady attention, and 
are marked by more exact and tangible results, all well calculated to check that 
roving movement of the mind, which, under whatever name it may pass, weakens 
its powers of self-control, and thus invites the approach of disease. ^ ^ 

" There is another disposition of mind to be carefully shunned by the class of 
persons in question — that of allowing the attention to be engrossed by some 
particular interest to the neglect of every other, even of those most nearly con- 
nected with the welfare of the individual. * ^ Where the mind of a person 
revolves in a very narrow circle of thought, it lacks entirely that recuperative 
and invigorating power which springs from a wider comprehension of things, 
and more numerous objects of interest. The habit of brooding over a single 
idea is calculated to dwarf the soundest mind ; but to those unfortunately con- 
stituted, it is positively dangerous, because they are easily led to this kind of 
partial mental activity, and are kept from running into fatal extremes by none 
of those conservative agencies which a broader discipline and a more generous 
culture naturally furnish. The result of this continual dwelling on a favourite 
idea is, that it comes up unbidden, and cannot be dismissed at pleasure. Eeason, 
fancy, passion, emotion — every power of the mind, in short — are pressed into its 
service, until it is magnified into gigantic proportions, and endowed with won- 
derful attributes. The conceptions become unnaturally vivid, the general views 
narrow and distorted, the proprieties of time and place are disregarded, the 
guiding, controlling power of the mind is disturbed, and, as the last stage of 
this melancholy process, reason is completely dethroned. These persons should 
be careful, therefore, how they suffer themselves to be led into the active support 
of those prominent moral and social enterprises that abound in every community. 
No matter what may be their convictions touching the necessity or justice of 
these projects, or the claims they make on the sympathy of all good and true 
men. They cannot join the ranks of those whose devotion to their favourite 
cause knows no stint or measure, without serious peril to their mental integrity. 
Let them, therefore, habitually feel that their mission in life lies in the quiet, 
unobtrusive performance of those duties which are incumbent on all, rather than 
in the promotion of enterprises which court the public gaze and stimulate their 
energies to the highest possible pitch. Let them not be beguiled by any fanci- 
ful obligations of duty, to quit the humbler sphere of effort most suitable to 
their mental capacities. There will always be enough to take the prominent 
places which they had better avoid, while no sphere of life is without its oppor- 
tunities of useful and honourable effort." * * 

Having thus written of the management of the intellect, the Doctor proceeds 
to that of the moral or emotional faculties. He believes that, " to some extent 
at least," persons "have the power of controlling their moral movements, and to 
that extent of hastening or retarding an attack of disease." Every person having 
a hereditary tendency to insanity should learn his own ruling sentiments, and, as 
no one can see himself as others see him, he should have those sentiments pointed 
out to him by his friends. These sentiments, making obliquities of character, 
are various. 

"In one, it is an inordinate love of money; in another, of fame and glory: in 
another, of reforming social evils; in another, of projecting great benevolent 
enterprises; in another, of intense religious excitement. The object pursued 
may not be intrinsically bad ; on the contrary, it may be highly commendable 
and worthy the attention of a rational being, and consequently the passion or 



1862.] 



American Insane Hospital Reports. 



169 



affection is indulged, until it shapes every movement and passes beyond the 
control of the intellect. In fact, the more commendable the object, other things 
being equal, the greater the danger, because entirely unsuspected. The daily 
experience of life furnishes abundant illustrations of the subject, but my limits 
forbid the notice of many. 

" The sentiment of benevolence, allying us, as it does, to the great Giver of all 
good, would seem, at first thought, less likely than any other to be the source 
of an unhealthy activity, and yet -when so strong as to be the predominant trait 
in the moral constitution, it is liable, in the class of persons under consideration, 
if not carefully watched, to lead to the most painful results. When thus in- 
dulged, life, duty, right and wrong, God and man. are often viewed solely by the 
light of this sentiment, with none of those softening shadows which the rest, 
under a more equal cultivation, would impart. Justice, discretion, expediency, 
even right, must all yield to the mere impulses of benevolence, which recognizes 
no degrees or shades in moral obligation. Oppression under any and every 
form must be immediately abated by an appeal to force; reforms are to be thrust 
upon the world, regardless of time and season ; abuses are to be torn up by the 
roots, careless of the healthy growth around that may be injured by the pro- 
cess ; and individuals are held to be responsible for any wrong with which they 
may be ever so remotely connected. Whatever is, is absolutely right or abso- 
lutely wrong, to be fondly cherished or summarily destroyed. Xo palliation of 
the evil is to be found in the attending circumstances; no remedy is to be tole- 
rated that implies any prospective change in the delinquent. Thus, it becomes, 
at last, to be regarded as a sacred duty to vindicate the claims of abstract bene- 
volence at whatever hazard, even though it lead through seas of blood and fire. 
Instances of this moral obliquity are not rare in the world, and so imperfectly 
is their character understood, that it is an equal chance whether they pass for 
fanatics, madmen, or hardened criminals. Looking at them in their true psycho- 
logical relations, we need to have no doubt on this point. Let those, therefore, 
to whom the warning is peculiarly necessary, who find themselves deeply inte- 
rested and engaged in promoting benevolent enterprises, reflect that, little as 
they may suspect it, every day is bearing them beyond the reach of those health- 
ful activities which prevent eccentric movements of the mind from passing over 
the limits of safety. 

"Again, no sentiment of our nature is more generally cultivated, in all Chris- 
tion communities, than the religious ; and, connected as it is with the highest 
interests of the individual, it is not strange that it should often be excessively 
exercised, and strained beyond the point of healthy endurance. In persons of 
ill-balanced minds, this result is almost inevitable, unless prevented by timely 
precaution and management. The elevated themes which engage their atten- 
tion are allowed to withdraw the mind from every other, apparently inferior 
object, with the usual result of narrowing the intellectual range, and disturbing 
that rightful balance of the faculties which always characterizes the most effi- 
cient order of minds. Gradually and unconsciously they reach a point where 
they have no thought for any thing else but their favourite themes. Intense and 
constant meditation upon them is followed, sooner or later, by its legitimate 
results — excessive extravagance of thought, unnatural rapidity of the mental 
movements, startling imagery, irrational combinations of ideas, and downright 
delusion." 

" The danger in this class of cases is all the greater, because the sentiment is 
pre-eminently social in its character, and its indulgence is greatly affected by the 
power of sympathy. The example of multitudes engaged in similar exercises, 
encouraging and emulating one lan other in the intensity of their feelings, has a 
mighty influence, even upon the most sluggish spirits, while upon those of mor- 
bid proclivities, it often operates with irresistible force, sometimes when least 
expected, and breaks down every barrier that reason can place in its way. This 
is not a rare and exceptional phenomenon. In the tables of causes contained 
in the reports of many of our hospitals for the insane, many cases are always 
attributed to ' religious excitement.' " 

(Two or three cases, from the thousands upon record, are here given.) 
The voice of admonition too often falls on unwilling ears, for people are 



ito 



Bibliographical Notices. 



[July 



slow to believe that exercises which are hip^hly meritorious, because leading to 
a good result, and prompted, perhaps, by divine influence, can, by any possi- 
bility, be dangerous to the mental health. Indeed, it seems to them little short 
of impiety to suppose it. Let them remember that they are yet in the flesh, and 
that no pursuit or exercise, however commendable, can be successfully followed 
by a system of means not in accordance with the laws of the animal economy. 
They may be sure that these will not be suspended to enable them to accomplish 
a desirable end ; and they may be also sure, that divine influences are always in 
harmony with those natural laws which have proceeded from the same beneficent 
source. Those who are sincerely desirous of guarding against the development 
of morbid tendencies, should carefully avoid all scenes of religious excitement, 
indulge their religious emotions in quiet and by ordinary methods, always allow- 
ing other emotions and other duties their rightful share of attention. Kegulated 
in this manner, the religious sentiment will be to them, not only a source of 
spiritual comfort, but a power more efficient, it may be than any other, for 
maintaining the healthy balance of the faculties, and keeping in abeyance the 
hereditary proclivities to disease." 

" If I have said nothing of the danger to be apprehended from the indulgence 
of other passions — envy, anger, jealousy, pride, fear or grief — it certainly is not 
because such indulgence is harmless to the health of the mind, even in those 
most fortunately constituted. In the ordinary intercourse of life, we not unfre- 
quently meet with persons who, with all the force of an instinct, view whatever 
passes around them with a jealous eye — ever ready to find, in the sayings and 
doings of others, evidence of hostility or unfriendliness to them, and to see, in 
the most trivial occurrences, matured designs of annoyance. They are con- 
stantly breaking with their best friends, and spend their whole life in converting 
the innocent occasions of private and public intercourse into pretexts for cold- 
ness and disafiection. In others, again, the ruling passion is envy. Their bless- 
ings, whether small or great, are of little satisfaction, because others are enjoying 
w^hat seem to them greater. Favors bestowed on others are regarded as proofs 
of the most culpable neglect of their superior deserts. They feel as if every 
one who has any reason to rejoice in the good things of life, is guilty of a positive 
wrong towards them, and bound to make restitution and recompense. Persons 
of this description — inheriting tendencies to disease and ruled by some pre- 
dominant passion — are never far removed from the brink of insanity, over which 
they are liable to be precipitated by the first adverse incident that severely tries 
their power of endurance. Early judicious discipline might have repressed the 
growth of the passion, and, to that extent, have secured the future integrity of 
the mind." 

2. Although the New Jersey State Lunatic Asylum is among a people who 
were somewhat cautious and tardy in the recognition of its excellence, its officers 
may now be well satisfied with the appreciation of its merits. In the language 
of the report — " the house has been much crowded through the entire year, 
notwithstanding the removal of a pretty large number — seventy-four — of chronic 
cases. 

" Many of these, though regarded as incurable, were still proper subjects for 
care and treatment in the asylum, and were only removed by the public authori- 
ties, or by friends, upon the urgent request of the officers of the institution, to 
make room for other and more necessitous cases." 



Patients in the asylum, December 31, 1859 . 
Admitted in the course of the year . 

Whole number 

Discharged, including deaths 
Remaining, December 31, 1860 . 
Of those discharged, there were cured 



Whole number of cases from May 15, 1848 

Pecovered 

Died 



Died . 



Men. Women. Total, 

141 165 306 

85 89 174 

226 254 480 

72 98 170 

154 156 310 

28 45 73. 

15 8 23 

830 907 1737 

320 358 678 

123 106 229 



1862.] 



American Insane Hospital Reports. 



171 



Deaths in 1860. — From consumption, 2; epilepsy, 3; exhaustion of acute 
mania, 9 ; apoplexy, 1 ; softening of brain, 1 ; exhaustion of chronic mania, 4 ; 
dropsy, 2 ; uncertain," 1. 

In two cases of fatality from the exhaustion of acute mania death occurred 
within a few hours after the patients arrived at the hospital. Dr. Buttolph very 
properly remarks, that "it is often an important question to decide whether a 
patient in an acute attack, who has been several days and nights without regular 
food and rest, and who has made much exhausting effort, may not be too much 
prostrated in strength to bear a fatiguing journey from home to the asylum. 
The removal should at least be advised by the medical attendant in charge, who 
should point out such precautionary measures in accomplishing it as will tend 
to relieve the patient, as far as possible, of exhausting effects." 

In view of the crowded state of the hospital, and the numerous applicants for 
its benefits, Dr. Buttolph, after asserting that additional accommodations for 
the insane of the State are urgently demanded, discusses the question whether 
those accommodations shall be obtained by the enlargement of the present hos- 
pital, or by the erection of another. He concludes that, notwithstanding the 
present number of patients in his establishment is upwards of 300, " the number 
may be somewhat increased without materially increasing the difficulty of its 
oversight." He mentions the numerous advantages of the location, and pro- 
poses, "if the policy of enlarging the present structure be adopted, to provide 
rooms for one hundred more patients." 

Three hundred and ten (the present number), plus one hundred, equals /oitr 
hundred and ten. How happens it that "in the abstract," "theoretically," "as 
a general rule," the members of the Association of Medical Superintendents 
assert that tiuo hundred and fifty is the utmost proper limit to the number of 
patients in a hospital, and yet, whenever the principle is to be adopted or 
rejected in any one of their individual cases, they " go in" for the enlargement 
ad libitum of their already overgrown establishments. " Logic is logic," but 
theory is not always practice. 



219 


153 


372 


31 


24 


55 


250 


177 


427 


28 


20 


48 


222 


157 


379 


18 


10 


28 


9 


8 


17 



3. The report before us of the Western Lunatic Asylum of Virginia embraces 
a period of fourteen months, ending with the 30th of November, 1860 ; and, 
although Dr. Stribling is not remarkable for prolixity, he has, in this instance, 
been unwontedly brief. 

Men. Women. Total. 

Patients, October 1, 1859 .... 
Admitted in course of fourteen months 

Whole number 

Discharged, including deaths 
Eemaining, November 30, 1860 . 
. Of those discharged, there were cured 
Died 

It appears that a very large proportion of the patients in this hospital are 
incurable, and as no provision has here been made for the removal of harmless 
cases of this class, either to their homes or to other receptacles, the number of 
admissions is small for so large an insti1?ution. Of 250 applicants in the course 
of fourteen months, only 53 were received. These, as was supposed, were such 
as were the most curable, and were selected, in the exercise of a discriminative 
power, by the Superintendent. The exercise of the power mentioned often, as 
may readily be conceived, gives offence, and Dr. Stribling suggests that a law 
be enacted for the removal of old demented cases to the county almshouses, thus 
opening the way to a more general admission of new applicants. 

A third hospital for the insane within the State is thus mentioned in the 
report : " I am not apprised as to when it is expected, by those in charge, to 
have accommodations for the insane at Western Virginia. If the entire build- 
ing being erected must be completed before patients are admitted we can but 
fear the day is somewhat remote when these sufferers will find an asvlum there." 



172 



Bibliographical Xotices. 



[July 



4. The report for 1860, of Dr. Parker, of the State Lunatic Asylum of South 
Carolina, is brief, and presents but few points of other than local interest. 



Patients at the beginning of the year 194 

Admitted in course of the year 69 

Whole number 263 

Discharged, including deaths 71 

Remaining at the end of the year 192 

Of those discharged, there were cured 37 

Died 26 



Of the 192 remaining at the end of the year, 86 were males and 106 females. 
The predominance of females is attributed to the rejection of many male appli- 
cants, for the want of proper accommodations. An additional section to the 
new building is in progress. 

" There has been an unusual number of applications for the admission of male 
slaves. The removal of all males from the old buildings and grounds made it 
necessary to remove the coloured patients of that sex, since which time we have 
had no place for that class. In consequence, many persons in the country are 
embarrassed with insane servants, and earnestly beg that influence be exerted 
with the legislature for some provision to be made which will relieve them from 
the responsibility and danger of keeping such patients at home, without the 
proper means of their comfort and cure. Insane coloured women we continue 
to receive, and have been fortunate in sending several to their homes, ready and 
competent to discharge their usual duties. 

" Since the occupancy of the old building exclusively by females, it has under- 
gone repairs and is improved in many respects, especially in the general arrange- 
ment and classification of the patients, all of which is very perceptible, and has 
been productive of uniform contentment among them. 

" To Miss D. L. Dix we are largely indebted for her prompt response to an 
invitation extended by the Regents. At their call she visited our Asylum, with 
peculiar interest in behalf of its inmates, though herself in feeble health, spent 
her time at the capital, and with indomitable zeal and perseverance, discreetly 
and modestly exercised, successfully brought to the notice of every member of 
our Legislature the claims of our insane." 

5, The subjoined statistics are taken from the report of the Northern Ohio 
Lunatic Asylum, for the fiscal year ending October 31, 1860 : — 



Men. Women. Total. 

Patients at the beginning of the year . .66 72 138 

Admitted in the course of the year . . . .o2 63 II.t 

Whole number 118 13.5 253 

Discharged, including deaths . . . . 54 64 118 

Remaining at the end of the year ... 64 71 135 

Of the discharged, there were cured ... 23 31 54 

Died 2 2 



Died from "exhaustion," 1 ; congestion of the brain, 1. 

"The health of the inmates," says iTr. Kendrick, " has been uniformly good 
during the year. The physical disorders incident to hospital life have been mild 
in form and readily controlled by ordinary hygienic precautions and simple 
remedies. A procrusteau plan of treatment is as little applicable to the insane 
as to the sane. We do not think of adapting the patient to the remedy in phy- 
sical disease ; so in mental disorder, which is but a manifestation of a diseased 
brain, we must modify our treatment to suit the varying wants of each case. 

" The nearer the approach to individualized treatment in our hospitals — 
other things being equal — the greater the success. The percentage of recoveries 
will be increased in direct ratio with the increase of resources ; proper classifica- 
tion, appropriate labour, constant mental employment, so diversified as not to 
weary, are indispensable to a successful treatment of the insane. They may as 
well be confined in the infirmaries and jails of their counties as in our public 



1862.] 



American Insane Hospital Reports. 



IIS 



hospitals, if debarred, by narrow rainded views of economy, from that extensive 
range of employment and amusement now so universally furnished the insane in 
curative institutions. I am sorry to say that our institution is behind the age 
in these respects. Great changes must take place to bring it up to that high 
standard of excellence, to which a worthy ambition prompts us to aspire." 

6. The general results of treatmenl at the Hamilton County [Ohio) Lunatic 
Asylum, for the year ending June 5, 1859, were as follows : — 



Patients at the beginning of the year 
Admitted in the course of the year 
Whole number .... 
Discharged, including deaths 
Remaining at the end of the year 
Of the discharged, there were cured 
Died 



Men. Women. 
112- 118 



105 
217 

74 
143 

43 
5 



59 
177 

47 
130 

19 

12 



Total. 

230 

164 

394 

121 

273 

62 

17 



Died from maniacal exhaustion, 3 ; nephritis, 2 ; epilepsy, 2 ; marasmus, 2 ; 
chronic dysentery, 2 ; purpura, 1 ; paralysis, 1 ; gastritis, 1 ; phthisis, 1 ; delirium 
tremens, 1 ; suicide, 1. 

"As heretofore, and as must always necessarily be the case under conditions 
similar to those affecting us, the diseases attacking our inmates, no matter what 
may have been their type primarily, speedily assume an asthenic character, 
requiring the most prompt, efficient and persistent stimulating plan of treatment 
to successfully combat them." 

Of the 394 patients, 289 were foreigners and 105 natives of the United States. 

" From changes of scene, of climate, and mode of life, separation from friends, 
regrets and yearnings for home, annoyances and misfortunes suffered and diseases 
contracted on ship passage, disappointed prospects, blighted hopes, poverty, ill 
health, and the too general prevalence of intemperance — that fruitful source of 
insanity among them — many a poor emigrant is driven to madness who would 
never have been bereft of reason had he lived and died in his native land." 

It will perhaps be remembered, that the buildings of the Hamilton County 
Asylum were intended only for temporary use. At the time of the publication 
of the report before us, the new buildings specially erected for the institutioQ 
were far advanced toward completion. 



7. The report for 1858 of the Insane Asylum of California, extends over a 
period of but eleven months, the official year being made to close with the close 
of the month of November. 



Patients in asylum Jan. 1st 

Admitted 

Whole number .... 
Discharged, including deaths 
Remaining Nov. 30th . 
Of the discharged, there were cured 
Died 



Men. Women. Total, 



156 


32 


188 


201 


43 


244 


357 


75 


432 


133 


26 


159 


224 


49 


273 


88 


24 


112 


30 


2 


32 



The diseases terminating fatally are not reported. 

" In California," says Dr. Aylett, " the sick have few friends, and are therefore 
quickly dispatched to the hospital. In this way the heartless stranger proves, 
really, the best friend of the poor lunatic." The very large proportion of cures 
at this hospital, as shown by the foregoing statistics, is undoubtedly, as inti- 
mated in the report, to be attributed to the fact that the patients are placed 
under hospital treatment at a very early period of the disease. "We here have 
a practical argument in favour of early treatment which should be neither over- 
looked nor forgotten. 

Dr. Aylett's report is brief, and mostly confined to the financial department 
of the hospital. We infer from it that an economy so rigid is required that there 



174 



Bibliographical Notices. * [July 



i?s an impossibility of furnishing those abundant facilities for moral treatment 
which are found at some other institutions. "For a few months," says he, "we 
had the use of a billiard-table, for which we were indebted to the kindness of 
Mr. Butler, the architect of the late improvements. I was surprised to find 
how much interest was taken in the game by some of the patients, who were 
thus beguiled of many a tedious and melancholy hour." 

But the following extracts have a pleasant look : "I do not hesitate to say 
that the improvements effected by the labours of the patients in the last twelve 
months would have cost, at the usual rate of labour, at least fifteen thousand 
dollars. * * * After the month of May, I hope and expect to dispense with a 
vegetable bill altogether. We have one thousand thrifty trees, of all varieties 
of fruit, from which we may expect a most abundant crop in a couple of years. 
We ought to set out about three thousand grape-vines this winter, and for this 
. purpose, and for the purchase of tools, seeds, etc., we need an appropriation of 
five thousand dollars." 

8. The Wisconsin State Hospital for the Insane was begun several years ago, 
but its progress toward completion was checked by many obstacles, both finan- 
cial and political. The officers first elected having been removed, others were 
appointed to their places, and, after many vicissitudes, the central building and 
one wing of the hospital were prepared for the reception of patients. The es- 
tablishment was opened on the 14th of July, 1860, under the care of Dr. John 
P. Clement, who had previously been connected, as Assistant Physician, with 
the Hospital at Brattleboro', Vermont. The Trustees, in their report, present 
to the Governor, and through him to the people of the State, the following con- 
solatory and congratulatory words : — 

"As some relief to the disappointment and vexation which this institution 
has hitherto created upon the public mind, we are now able to present the con- 
soling intelligence that when the balance of indebtedness above set forth 
($50,000) shall have been paid, the committee believe that no remaining debt 
will exist against the institution from any source whatever. It argues much, in 
behalf of the generosity of the people of Wisconsin that in the midst of unpa- 
ralleled pecuniary embarrassments, they have contributed directly and so largely, 
from their scanty means, to procure the erection of this much needed institution, 
for the relief of that unfortunate class of their fellow-citizens who have been 
deprived of their reasoning faculties. But they have at length the cheering 
consolation, that through much struggling and adversity, they have patiently 
persevered in behalf of such as are deprived of those noble attributes which 
constitute the manhood of man, till they have succeeded in establishing a proud 
and enduring monument to their humane instincts, and sympathizing benevolence. 
And, though the struggle has been long and arduous, we are happy to believe, 
that with a little more skirmishing, the victory will be completely and nobly 
won," 

The report is dated December 16th, a little more than five months after the 



hospital was opened. 

Men. Women. TotaL 

Patients received to that time .... 43 46 89 

Discharged, including deaths .... 3 8 11 

Kemaiuing^ 40 38 78 

Of the discharged, there were cured ... 3 

Died 3 



Died from exhaustion in puerperal mania, 1 ; phthisis, 1 ; softening of the 
brain, 1, 

" Of those remaining, four at least have recovered and will soon be discharged, 
making the recoveries seven in all. There are, perhaps, ten others whose reco- 
very may be reasonably expected. A few others will probably be sufficiently 
improved to render their return home advisable. 

" The large number of remaining cases are incurable, and incapable of any 
material improvement. Still, their condition is ameliorated by care and treat- 
ment in an institution specially designed for them. The violent are managed 



1862.] Brown-Sequard, Paralysis of the Lower Extremities. 175 

with much less restraint and coercion than would be necessary at their homes, 
or in jails and poor-houses. The filthy are often rendered more cleanly, and the 
noisy more quiet and orderly. The homicidal often become harmless. Two 
patients are now quietly walking our wards, whom it was thought necessary to 
chain, for a long time, at their homes." 

Dr. Clement alludes to the evils arising from the attempt to treat both sexes 
in one wing of the building, as well as from the gathering of nearly a hundred 
patients into apartments designed for but about thirty, and appears anxious to 
have another section of the edifice erected. P. E. 



A RT. XYIT. — Lectures on the Diagnosis and Treatment of the Principal Forms 
of Paralysis of the Loiver Extremities. By E. Brown-Sequard, M. D., F. R. S., 
Fellow of the Royal College of Physicians of London, Hon. Fellow of the 
Faculty of Physicians and Surgeons of Glasgow, Laureate of the Institute of 
France (Academy of Sciences), etc. etc. 8vo. pp. 118. J. B. Lippincott & 
Co. : Philadelphia, 1861. 

The substance of this excellent work originally formed part of a course of 
lectures on various subjects delivered by Dr. Sequard, in April and May, 1859, 
to classes of physicians and students in the Universities of Edinburgh and Glas- 
gow, and in DulDlin. Its leading object is to point out the extreme importance 
of a clear diagnosis of the various forms of paralysis of the lower limbs, and 
especially of the two most frequent and distinct varieties, viz. : reflex paraplegia 
and paralysis due to myelitis. 

In the treatment of paraplegia it is well known that strychnia, brucia, phos- 
phorus, sulphur, mercury, ergot, belladonna, and cantharides, have been em- 
ployed, sometimes with marked benefit and sometimes with injury to the patient. 
These drugs differ very considerably in their action upon the spinal cord. Some 
of them, as strychnia and brucia, increase the quantity of blood in the vessels 
of the medulla, while others, as mercury, ergot, and belladonna, diminish it. It 
is very evident, therefore, that if we do not carefully discriminate between the 
different kinds of paraplegia we must often commit serious errors in the treatment 
of this disease. For all the cases of paraplegia are divisible into two general 
groups : one in which there is an excessive quantity of blood circulating in the 
spinal cord ; the other, in which the amount of this fluid is too small. Now the 
whole history of reflex paraplegia shows that it is accompanied, and most likely 
produced, by an insufficiency of blood in the cord. Remedies tending to dimi- 
nish the quantity of this fluid still more should, therefore, be avoided. Never- 
theless, mercury is often and very unwisely employed in the treatment of just 
such cases. On the other hand, cases of myelitis, in which the opposite condi- 
tion exists, are often treated with strychnia, the very remedy which so decidedly 
increases the amount of blood in the cord. 

In his second lecture our author places the practical physician under great 
obligation by carefully detailing the striking differences which exist between the 
symptoms of reflex paraplegia and those of the various forms of paraplegia of 
centric origin. In the following table which we borrow from his pages, and 
which is based upon numerous cases observed by Stanley, Rayer, Leroy d'Etiol- 
les, Jr., Landry, Macario, Spencer Wells, Sequard himself, and others, are con- 
densed the principal features of two of the most characteristic varieties of reflex 
and centric paralysis of the lower extremities — -the paraplegia due to a reflex 
influence originating in the urinary organs and the paraplegia produced by 
myelitis : — 

URINAEY PARAPLEGIA. PARAPLEGIA FROM MYELITIS. 

1. Preceded by an affection of the blad- 1. Usually no disease of the urinary or- 
der, the kidneys, or the. prostate. gans except as a consequence of the para- 
lysis. 

2. Usually lower limbs alone paralyzed. 2. Usually other parts paralyzed besides 

the lower limbs. 



176 



Bibliographical Notices. 



[July 



TJKINARY PARAPLEGIA. 

3. No gradual extension of the paralysis 
upwards. 

4. Usually paralysis incomplete. 

5. Some muscles more paralyzed than 
others. 

6. Reflex power neither much increased 
nor completely lost. 

7. Bladder and rectum rarely paralyzed, 
or, at least, only slightly paralyzed. 

8. Spasms in paralyzed muscles extremely 
rare. 

9. Very rarely pains in the spine, either 
spontaneously or caused by pressure, per- 
cussion, warm water, ice, &c. 

10. No feeling of pain or constriction round 
the abdomen or the chest. 

11. No formication, no pricking, no dis- 
agreeable sensation of cold or heat. 

12. Anaesthesia rare. 

13. Usually obstinate gastric derange- 
ment. 

14. Great changes in the degree of the 
paralysis corresponding to changes in the 
disease of the urinary organs. 

15. Cure frequently and rapidly obtained, 
or taking place spontaneously after a nota- 
ble amelioration or the cure of the urinary 
affection. 

In cases of myelitis the urine is almost always alkaline: while in cases of 
reflex paraplegia, not depending upon a disease of the urinary organs, it is 
usually acid, as in health. Paraplegia depending upon spinal meningitis may 
be distinguished from reflex paraplegia by a rigid spasm of the muscles of the 
back by the intense pain caused by motion of the lower limbs or of the spine, 
or by the spontaneous acute pains that radiate from the spine to the lower 
extremities, and the frequency of cramps. AYhen paraplegia is produced by 
the pressure of a tumour, a diseased bone, or fibro-cartilage upon the spinal cord, 
there is usually a feeling of tightness, or pseudo-neuralgic pain, or a degree of 
formication, only in the parts of the body receiving their nerves from that part 
of the cord which is pressed upon, unless there is a myelitis or a meningitis, in 
which case these symptoms may exist in all parts of the body below the seat of 
pressure. At this point there is also pain or tenderness. In cases of paralysis 
of the lower limbs produced by a tumour in the gray matter of the spinal cord 
anaesthesia appears at the onset of the affection, and may be more marked than 
the loss of motor power. Keflex power in the parts of the cord below the tumour 
becomes extremely exalted, so that very slight excitations will produce the most 
violent reflex movements. The only great differential characteristic of hysterical 
paraplegia is, that the paraplegia has followed hysteria. Our author thinks it 
probable that in most cases, if not in all, hysterical paralysis is but a reflex para- 
lysis. Paraplegia caused by hemorrhage in the spinal canal is characterized by 
the existence of a vague pain along the spine some time before the paralysis 
appears by the suddenness of its appearance, and by the very frequent occur- 
rence of violent convulsions, or, at least, of spasmodic twitchings. When blood 
is efi'used into the gray matter of the spinal cord the resulting paraplegia appears 
suddenly and is always accompanied by a notable diminution of sensibility. In 
paraplegia produced by congestion of the spinal cord and its membranes, the 
patient, on rising after a night's rest, is much more paralyzed than when he has 
been moving about, or has remained in a sitting posture for some time. • The 
reverse of this is usually observed in reflex paralysis. Paraplegia is sometimes 
caused by non-inflammatory softening of the cord, and may be distinguished 
from reflex paralysis by the absence of any external cause of spinal irritation, 



PARAPLEGIA FROM MYELITIS. 

3. Most frequently a gradual extension of 
the paralysis upwards. 

4. Very frequently paralysis complete. 

5. The degree of paralysis is the same in 
the various muscles of the lower limbs. 

6. Reflex power often lost, or sometimes 
much increased. 

7. Bladder and rectum usually paralyzed, 
completely or nearly so. 

8. Always spasms, or, at least, twitchings. 

9. Always some degree of pain existing 
spontaneously, or caused by external exci- 
tations. 

10. Usually a feeling as if a cord were tied 
tightly round the boundary at the upper 
limit of the paralysis. 

11. Always formications, or pricking, or 
both, and very often sensations of heat or 
cold. 

12. Angesthesia very frequent, and always, 
at least, numbness. 

13. Gastric digestion good, unless the 
myelitis has extended high up in the cord. 

14. Ameliorations very rare, and not fol- 
lowing changes in the condition of the uri- 
nary organs. 

15. Frequently a slow and gradual pro- 
gress towards a fatal issue ; very rarely a 
complete cure. 



1862 ] Beown-Seqtjard, Paralysis of the Lower Extremities, 111 



by the very slow development of the paralysis, and sometimes by the arcus 
senilis, and the presence of a calcareous deposit in superficial bloodvessels of 
the head or limbs, &c. Paraplegia due to an obstacle in the circulation of blood 
in the aorta, or in its principal ramifications in the pelvis, may be recognized by 
the alternations of nutrition and pains in the paralyzed limbs, and especially by 
the rapid increase of the paralysis after every notable exertion of the lower limbs, 
and the return of some power after rest. Paraplegia resulting from pressure 
on the pelvic nerves is accompanied by violent pains in the pelvis and in many 
parts of the lower limbs by the production of cramps, &c. 

Our author denies the existence of cases of the so-called essential or idiopathic 
paraplegia, and maintains that other forms of this disease, such as those which 
are connected with gout, rheumatism, or those which follow grave fevers, cholera, 
&c., either depend upon venous congestion of the cord, and serous effusion into 
the spinal canal, or belong to the group of reflex paralyses. Paraplegia is 
sometimes a result of poisoning by carbonic acid, lead, arsenic, mercury, opium, 
belladonna, tobacco, camphor, mushrooms, fish, &c. Great loss of blood, con- 
cussion, fracture, or luxation of the spine, also produce this disease. In all such 
cases the diagnosis is rendered easy by a knowledge of the cause. 

In treating a case of reflex paraplegia our remedies must first be directed 
against the external cause of the affection, and, secondly, against the paralysis 
itself. The nephritis, cystitis, pneumonia, enteritis, or other morbid condition 
which may be the cause of the paralysis, must be carefully treated. In the next 
place we should endeavour to prevent or to diminish the transmission of any 
nervous influence from the diseased nerve or organ to the spinal cord. For this 
purpose we must try, by the use of narcotics and anodynes, to paralyze for a 
time the sensitive nerves engaged in conveying the morbid influence. To di- 
minish pain or to prevent reflex action, no narcotic is more powerful than bella- 
donna locally employed. 

" In cases of disease of the urethra or the prostate, an injection of a solution 
of one grain of the extract of belladonna, in twenty drops of laudanum, is to be 
made into the urethra, and the injection should be retained half an hour, or even 
an hour, after which some emollient decoction should be employed to wash away 
the rest of the narcotics. Every two or three days the same operation should 
be repeated. In the intervening days, I advise the use of an injection of thirty 
drops of laudanum without belladonna. In cases of a disease of the bladder, I 
recommend the use of an injection into the bladder of a solution of one grain of 
the extract of belladonna, in twenty drops of laudanum, just after a complete 
emission of urine. One day this injection is employed, and the next day twenty- 
five or thirty drops of laudanum alone are injected. When the prostate is very 
much enlarged, a suppository, covered with a belladonna-and-opium ointment, 
ought to be put at times in the rectum. 

" When the irritation that causes a reflex paraplegia starts from the vagina 
or the uterus, a pill of half a grain, of extract of belladonna with one grain of 
extract of opium, surrounded by a piece of cotton wool, is introduced far into 
the vagina, and even up to the neck of the uterus. By means of a thread at- 
tached to the cotton, it is withdrawn as soon as the pain has ceased or much 
diminished. This simple means I have seen often employed with benefit by my 
learned teacher, Professor Trousseau, in painful- affections of the womb, and I 
have myself made use of it with great advantage in two cases of reflex para- 
plegia, and in several cases of hysterical paralysis. 

" In cases of a reflex paraplegia due to dysentery, colitis, or other morbid 
irritations of the large intestine, accompanied by diarrhoea, opium alone — z, e., 
without belladonna — should be employed in enemata. In cases of paraplegia 
due to teething, if it coexists with enteritis, as it often does, opium is the nar- 
cotic to be employed, and it should then be taken by the mouth in very small 
but repeated doses. In cases of neuralgia producing a paraplegia, the narcotic 
that should be chiefly employed to relieve pain is opium, and so also in cases of 
paraplegia due to a disease of the stomach, the liver, the kidneys, the pleura? ; 
but even in all these cases, belladonna may be used with profit if united with 
opium, if it is not often employed, and especially if strychnine is also used at the 
same time. I could not insist enough upon the importance of the necessity of 
No. LXXXYII.—JuLY 1862. 12 



178 



Bibliographical Notices. 



[July 



never using belladonna -without employing-, at the same time, strychnine and 
opium, or, at least, strychnine, in cases of reflex paraplegia. I must repeat, also, 
that in this affection, when belladonna is employed, its use ought not to be a 
constant one ; and, if the patients are not very costive, opium ought always to 
be the principal narcotic used to alleviate the external irritation that causes the 
paralysis." 

The great object of this narcotic treatment is to bring about dilatation of the 
bloodvessels of the spinal cord, and a consequent increase in the amount of blood 
circulating in these vessels. 

Excitants or revulsives applied to the skin of the legs, as recommended and 
successfully practised by Graves, the application of cold to the spine, and the 
employment of galvanism are all very useful in the treatment of many cases of 
reflex paraplegia. Their mode of action probably consists, according to our 
author, in producing for a short time the same effect as the irritation, which is 
the cause of the paralysis — i. e., a contraction of the bloodvessels of the spinal 
cord ; but. according to a well-established law, if such a contraction becomes 
considerable, the muscular fibres are soon exhausted, and a relaxation of the 
contracted fibres takes place, and, as a consequence of this relaxation, a dilata- 
tion of the bloodvessels occurs. 

" To those patients who can bear the application of very cold water to the 
spine," says Dr. Brown-Sequard, "I prescribe the use of a douche thrown with 
great force all along the dorsal and lumbar regions of the spine. The douche 
should be applied for one minute or a minute and a half ; it ought to be supplied 
with a small jet, and the temperature of the water should be between 40^ and 
50^ Fahr. I need hardly say that the spine must be rubbed hard with a warm 
flannel immediately after the application of the douche. In patients who can- 
not bear the cold douche, a very warm douche should be made use of. I some- 
times make use of alternate applications of cold and heat, either with sponges 
— one soaked with ice-water, and another with water at 100^ Fahr. — or a towel 
folded somewhat like a cravat, the two ends of which are wet, one with ice-water, 
the other with warm water, the spine being struck with either end of this towel 
alternately." 

In order to increase still further the quantity of blood in the spinal cord. Dr. 
Brown-Sequard gives the following directions concerning the position of the 
patient in bed. 

" Every night, and often in the course of the day, the patient should lie down 
on his back, placing his head, his arms, and his legs, on high pillows, so as to 
produce by gravitation a congestion in the spinal cord. This simple means, 
which is also applicable in cases of hysterical paraplegia, and in almost all the 
cases in which there is an insuflBcient amount of blood in the spinal cord, is just 
the reverse of what should be done in cases of inflammation or congestion of 
the spinal cord or its membranes, or of disease of the spine, <fcc., in which cases 
the patient ought to lie flat on the abdomen, or on one side of the body, and 
have his feet and hands on a much lower level than that of the spine." 

The remedies most useful in cases of reflex paraplegia are essentially those 
which increase the amount of blood in the spinal cord, and augment the vital 
properties of this nervous centre. Remedies which render the blood richer in 
nutritive principles are also requisite. Of all known agents strychnia most 
powerfully increases the vascularity, and, consequently, the nutrition of the 
cord. The researches of Bonnefin have shown that morphia, nicotine, picro- 
toxine, cyanuret of mercury, sulphuret of carbon, chloride of barium, oxalic 
acid, &c., seem to act like strychnia upon the medulla spinalis. Compared with 
the latter remedy, however, they are deserving of but little confidence in the 
treatment of reflex paraplegia. In this disease, as we have already seen, the 
amount of blood in the cord, and the reflex faculty of this organ, are both di- 
minished. As strychnia counteracts both these conditions — or, in other words, 
increases most decidedly the quantity of blood, and the reflex power of the, cord 
— it becomes, in the hands of the discriminating physician, a powerfully curative 
agent. "When used alone, one-twentieth of a graiu should be given in the course 
of a day. When employed in conjunction with opium, the dose should be re- 
duced to from one-fortieth to one-thirtieth of a grain per day. When given in 



1862.] 



Sims, Tedder, Gay, Surgical Tracts. 



n9 



combination with belladonna, the dose must be larger, on account of the anta- 
gonistic action of belladonna on the spinal cord. Dr. Brown-Sequard also re- 
commends sulphuret of potash baths, made in the proportion of four or five 
ounces of the salt to sufficient water for a bath. 

In his third lecture, our author dwells at length upon the diagnosis and treat- 
ment of paraplegia due to myelitis, meningitis, and simple congestion of the cord. 
The fourth and last lecture is devoted to a consideration of the symptoms and 
treatment of the various forms of paraplegia produced by white, or non-inflam- 
matory softening of the cord, by hemorrhage into the substance of the medulla 
or into the vertebral canal, and by tumours pressing upon the cord. Both these 
lectures abound in such valuable information and suggestions relative to the 
nature and treatment of paralysis of the lower extremities, that we cannot too 
strongly urge a careful perusal of them upon those of our readers who may be 
called upon to treat cases of this troublesome and distressing affection. The 
work, as a whole, is free from mere theoretical discussion, and is remarkable for 
the clear and concise manner in which the facts of physiological and clinical 
observation are combined in the attempt to establish a scientific and successful 
method of treating the important disease under consideration. J. A. M. 



Art. XYIII. — Surgical Tracts. 

1. Amputation oftlie Cervix Uteri. By J. Marion Sims, M. D. Extracted 
from the Transactions of the State of New York, 1861. New York, 1861. 
8vo. pp. 16. 

2. Extension and Counter-extension in the Treatment of Fractures of the 
Long Bones ; with a Description of an Apparatus especially designed for 
Compound Fractures. By Joseph H. Yedder, A. M., M. D. New York, 
1862. 8vo. pp. 23. 

3. A Description of the newly -invented Elastic Tourniquet, for the Use of 
Armies and Employment in Civil Life, its Uses and Applications, ivith 
Remarks on the Different Methods of Arresting Hemorrhage from Gun- 
shut and other Wounds. New York, 1862. 8vo. pp. 31. 

4. On Intestinal Obstruction hy the Solitary Band. Being a paper read at 
a meeting of the Medical Society of London, March 25th, 1861, and re- 
printed from their Transactions. By John Gay, F. R. C. S., &c. London, 
1861. Printed for private circulation. 8vo. pp. 16. 

1. Dr. Sims records in this paper nine cases in which amputation of the 
cervix- uteri was performed by a method more simple and safer than the one 
usually adopted. The cervix is split laterally, and the anterior and posterior 
halves are removed by means of scissors. After the hemorrhage has ceased, 
the vaginal mucous membrane is drawn over the stump and secured by four 
sutures, two on each side of the cervical opening. According to this plan there 
is no suppuration, the parts healing by the first intention, and the parts becoming 
well in a week. In the old method of amputation, the suppuration continued 
five or six weeks, sometimes longer, before the parts entirely cicatrized. 

This paper is illustrated by four wood-cuts. 

2. The pamphlet of Dr. Yedder, though the title would lead one to look 
for something more, contains simply the description of some mechanical con- 
trivances for making extension and counter-extension in the treatment of 
fractures. 

The mode of making extension contrived by Dr. Yedder is that of having on 
the outside of the splint a ratchet pulley, into which is fastened a strong cat- 
gut cord or linen twine that runs over the extremity of the splint to be attached 
by various means to the broken limb. The ratchet, which is revolved by means 
of a thumb-plate or lever, is secured at any desired point by a spring catch. 

The apparatus of Dr. Yedder, as we learn by the report of the board of army 
surgeons appointed to investigate its merits — which report is attached to this 



180 



Bibliographical Notice.s. 



[July 



pamphlet — was recommended to be furnished to each hospital in Washington 
and Alexandria, for the purpose of fully testing its value. 

This pamphlet contains also a description of an admirable extemporaneous 
splint, which has already been proved by experience to be of great service in 
enabling wounded men to be transported with comparative comfort. We will 
give an account of it by transcribing the description as given by Dr. Foster 
Swift, surgeon 8th N. Y. State militia : — 

" After the battle of Bull Run, on the 21st of July last, we were left with four 
or five cases of fractured arms, with no appliances for their treatment, and with 
the prospect of their transportation over a rough road in rough wagons to 
Manassas, and thence to Richmond. Without splints, and without any light 
material to make them of, I am indebted to Dr. Hoges, of one of the Mississippi 
regiments in the rebel army, for the following simple contrivance, which afforded 
great relief to our wounded men in their jolting journey. Two strips of adhe- 
sive plaster were cut two feet in length and three inches in width, one of which 
was carried over the upper fragment to the point of fracture, leaving the loop 
above ; the other was carried in a similar manner over the lower fragment, 
forming a loop below. A piece of board about one foot longer than the frac- 
tured limb, with a Y-shaped piece removed from each end, was then applied to 
the arm. The lower loop was tied by a bandage to the lower Y, and the upper 
loop to the upper Y. The fragments were thus separated, and the limb could 
be secured to the splint by a simple turn of the bandage, above and below the 
point of fracture, thus leaving the orifice of the entrance and exit of the ball 
open." 

In place of the board, the surgeon may use two straight branches of a tree, 
of suitable size and length, having a fork at one end, over which the bandage 
attached to the loops may be tied. If one branch be let into the other by a 
notch before they are bound together, the splint will be firm enough to bear 
any pressure. 

3. The newly-invented elastic tourniquet, described in the anonymous publi- 
cation, placed on the list with the preceding, is the invention of Dr. T. S. 
Lambert, of New York. 

It certainly is an instrument po'ssessing peculiar advantages, inasmuch as it 
only interrupts the flow of blood through the principal arteries of the limb. 

The object of this publication is evidently to set forth the advantages of the 
employment of this form of tourniquet in military surgery ; and the testimonials 
attached declare that " every officer in our army, from the lowest grade to a 
general, should have one, and at his leisure moments teach the men of their 
regiments how they are to be applied," and that " one should be furnished to 
every soldier in the field." These testimonials, it is scarcely necessary to add, 
are from, civil practitioners. We do not believe ourselves that if every general 
and other officer of the United States army would devote all his leisure time to 
teaching how the tourniquet should be applied, and if every soldier in the field 
would stop his work to put one on so soon as he felt himself struck, that the 
mortality would be appreciably, if at all, diminished, and the disadvantages 
attending such proceedings are flagrant. 

4. The design of the paper of Mr. Gay on " Intestinal Obstruction by the 
Solitary Band" is to aid in the diagnosis, and, consequently, in the treatment 
of cases of internal obstruction. Such cases are more frequent than is gene- 
rally supposed, for, in the Reports of the Registrar-General for 1855, 420 
males and 435 females are said to have died of " obstruction of the bowels," 
independently of deaths from the various forms of hernia. It often happens, 
on the post-mortem examination of such cases, that a state of parts is found 
which might have been relieved during life by the intervention of the surgeon ; 
and one of the most frequent is the presence of a band, forming by its terminal 
attachroents a ring into which a portion of intestine has glided and there become 
strangulated. From the antecedent history, the mode of attack, and the sensa- 
tional, the physical, and the functional indications, Mr. Gay believes that a 
reasonable conclusion may be arrived at in regard to the presence of a band as 



1862.] 



Smith, Handbook of Surgical Operations. 



181 



the cause of the obstruction. The evidences upon which he lays most stress 
are : — 

1. An antecedent abdominal affection of such severity as to lead the surgeon 
to believe that it might have been attended with some ulcerative or perforative 
process of either the bowel or the mesentery. For the repair of these intestinal 
injuries, lymph is poured out, and afterwards becomes stretched into a baud, 
which may be even twenty inches in length. 

2. Suddenness of the attack, without previous visible deterioration of the 
patient's health. 

3. Pain, first localized, then tenderness over a large area. 

4. Distension, with general dulness at first, and subsequent concentration of 
dulness and tension towards the original seat of pain. 

5. Vomiting, especially if it speedily becomes fecal. 

Mr. Gay believes that no such conjunction of symptoms as these can arise 
without some sudden alteration in the relation of parts within the abdominal 
cavity ; and that in most cases a bridle will be found to be either directly or 
indirectly constricting a portion of intestine. So soon as fecal vomiting has set 
in, the surgeon is, in his opinion, justified in proceeding to explore the abdomen. 

Mr. Gay's paper, of which we have given this slight sketch, is a very 
imperfect one, and we regret to see its publication, inasmuch as it is an 
evidence of a lack of proper information upon this interesting subject of inter- 
nal strangulation of the bowels. While the account given of the pathology 
and of the symptoms of this affection are altogether too meagre, nothing 
whatever is said as to our means of recognizing the portion of intestine that 
may be the seat of obstruction, nor as to the diagnosis of accompanying peri- 
tonitis, the existence of which must exert great influence upon the determina- 
tion of the surgeon. In the treatment we are only told that it is justifiable to 
explore the abdomen, or to open that cavity, and search for the strangulating 
band, and divide it, if any be found. No mention is made of the formation of 
an artificial anus, which has often been, practised with success in these cases, 
and which is an operation applicable to all cases of intestinal obstruction. 

W. F. A. 



Art. XIX. — HandhooTc of Surgical Operations. By Stephen Smith, M.D., 
Surgeon to Bellevue Hospital. New York : Bailliere Brothers, 1862. 12mo. 
pp. 279. 

This volume is designed especially for the use of military surgeons, and is 
therefore exclusively devoted to the consideration of those branches of operative 
surgery which are of most importance in the surgery of war. 

It is divided into six chapters, entitled respectively "mmor surgery'' ^' on 
the arteries," " on the veins,'' " o?2 amputations," " on resections," and " on gun- 
shot wounds." 

The second, third, fourth, and fifth chapters, which constitute the great part 
of the work, contain an admirable exposition of the subjects to the consideration 
of which they are devoted, and they may be consulted by every surgeon with 
pleasure and profit. 

The chapter on resections is particularly valuable, and it may confidently be 
said to contain the best account of this important class of surgical operations 
that is to be found in the English language. 

The first chapter on minor surgery cannot be regarded as sufficiently full and 
complete to fulfil the purpose for which it is designed ; and the last chapter 
contains nothing novel, being mainly an abstract of the able article by Prof. 
Longmore in " Holmes' Surgery," and with which our readers are already ac- 
quainted. 

The book is published in a very convenient and portable form, and the text 
is abundantly illustrated by engravings judiciously selected from the most ap- 
proved works on operative surgery. W. F. A. 



182 



Bibliographical Notices. 



[July 



Aet. XX. — Transactions of the Obstetrical Society of London. Yol. III. 
8vo. pp. 480. London, 1862. 

The present volume, whicli comprises the Transactions of the society for the 
year 1861, does not in the slightest degree fall behind the two preceding ones 
either in the interest or value of its contents. Besides the President's Annual 
Address, it contains thirty-nine papers — chiefly reports of cases, or practical 
remarks on questions of importance in reference to obstetrics, or certain of the 
diseases of women and children. An abstract of several of these papers has 
already been presented to our readers in our quarterly summaries of the pro- 
gress of medical knowledge since the first of January of the past year. Of the 
remaining papers we shall proceed to present to our readers a short notice. 

The address of the President, Dr. W. Tyler Smith, is occupied, mainly, by a 
biographical sketch of Dr. Edward Rigby, who, for the first two years of the 
society's existence, filled the presidential chair with great ability, and so much 
to the satisfaction of the members, that, at the annual meeting held on the very 
day his remains were consigned to the tomb, they had intended to suspend the 
operation of the law which limits the tenure of office to two years,' in order that 
they might, as a mark of their high respect and approbation, elect him for the 
third time as their chief. 

Case of Fibrous Tumour of the Uterus. By T. H. Tanner, M.D., etc. — The 
patient was thirty-four years of age, of fine appearance, tall, and very stout. 
Had been married seven years. Supposed herself to have been, but, probably, 
without any foundation, twice pregnant, and on both occasions to have miscar- 
ried at the end of a few weeks. Had enjoyed good health to within a few years 
before her death. She first noticed that her catamenial discharge became much 
more profuse than usual. She had then for many months occasional floodings, 
which gradually became more frequent, and, finally, were replaced by a con- 
tinued hemorrhage from the uterus, which rendered the patient weak and exsan- 
guine. In the beginning of June, 1855, she applied to Dr. Tanner for medical 
aid. She was then feeble, and nervous, with loathing of food, a weak pulse, and 
frequent attacks of palpitation of the heart. By auscultation of the latter organ, 
a systolic, anaemic, bellows sound was detected, while a venous bruit was heard 
in the neck. Parietes of abdomen so loaded with fat as to prevent the condi- 
tion of the viscera within being detected. There was greater dulness over the 
hypogastric region than elsewhere, with a sense of resistance as from a solid 
tumour. Examination per vaginam showed that the cervix uteri was very 
high up, and the os very small, so as not to admit the passage of a small bougie. 

The diagnosis made by Dr. T. was the existence of a small foreign body of 
some kind in the uterus, and a tumour, probably ovarian or uterine, occupying 
the lower portion of the abdomen. 

The patient was directed to keep quiet in bed, to take plenty of nourishment 
and stimulants, and twenty grains of ergot, every six hours. Under this treat- 
ment she slowly improved ; at the end of about ten days the bleeding ceased. 
Quinine and acid mixture were then given, with a full animal diet, and she went on 
until the catamenia again appeared on the 9th of July. Astringents were imme- 
diately commenced with, and the discharge ceased in ten days. 

From this time until the patient's death, December 28, 1860, the hemorrhage 
recurred at every catamenial period, and was checked with great difficulty. 
Astringents of every kind, ergot, opium, galvanism, the application of ice, in 
fact, every remedy reputed beneficial in cases of uterine hemorrhage was fully 
tried, but all failed, finally, to produce the slightest good effect. From the irri- 
tability of the patient and the morbid sensibility of the vagina an effective plug 
could not be endured over twelve hours, even when opium was administered to 
diminish the uneasiness. The only remedy which had any eff'ect in checking the 
hem.orrhage was mercury, and to it the patient owed her life on several occa- 
sions. Its good effects were equally obtained whether the bichloride was given 
in doses of the sixteenth of a grain every six hours, or calomel administered to 
the extent of producing ptyalism. 



1862.] Transactions of the Obstetrical Society of London. 183 



During the last quarter of 1860 the patient became extremely exhausted, and 
suffered much from irritability of stomach, by which she was prevented, for 
several days at a time, from taking anything by the mouth. Without losing flesh, 
she became weaker and weaker, and, finally, sunk from pure anaemia. 

After death the body was found quite bloodless. The adipose tissue on the 
abdominal walls was two inches thick, while the vaginal labia looked like large 
folds of fat. The lower part of the abdomen was occupied by an oval cyst nearly 
nine inches broad, apparently formed beneath the peritoneum stretched upwards 
from the fundus uteri; it contained about a pint and a half of urinous looking 
fluid. A smaller cyst was also present containing two drachms of serum. The 
large cyst rested upon the expanded wings of the iliac bones and kept the uterus 
out of the true pelvis. The cavity of the uterus was found to contain a fibrous 
tumour, about the size of a small orange cut in two. It was attached, by its 
base or broadest part to the posterior wall of the uterus, and projected fully 
three-quarters of an inch into the uterine cavity. The other organs of the body 
were healthy. 

The larger cyst had probably commenced in the right broad ligament, which, 
with the Fallopian tube, it had gradually distended. The left Fallopian tube 
was dilated, and contained pus — not, apparently, of recent formation. 

Ovariotomy, with Cases and Remarks on the Different Steps of the Opera- 
tion, and the Causes of its Mortality. By W. Tyler Smith, M. D., etc. — Four 
cases are related in which ovariotomy was performed by Dr. Smith, in all 
with a favourable result. The cases, we are assured, were in no way selected ; 
two of them were unfavourable cases — one being of the worst form of ovarian 
disease, that which most nearly approaches to the character of malignancy. 
They are the only cases in which he has ever attempted anything beyond tapping 
with or without injection of iodine ; and never before could he point to an equal 
number of distinct and positive cures of ovarian disease. 

In a table compiled by Mr. Clay, showing the special causes of mortality in 
150 cases of ovariotomy, 17 per cent, of the fatal cases occurred from shock or 
collapse produced by the operation. This source of fatality Dr. S. proposes to 
avoid by a more early resort to the operation. This would lessen, also, the 
number of cases of adhesion between the ovarian cyst and other organs. Ex- 
cepting in cases where this adhesion is intimate and extensive he can see nothing 
necessarily belonging to the operation, which, with the use of chloroform, should 
produce a dangerous shock. 

According to the same table 16 per cent, of the fatal cases were due to hemor- 
rhage. All, or nearly all of these, according to Dr. S., should have been pre- 
vented by care in the application of the ligature to the pedicle, and in securing 
hemorrhage connected with adhesions. One source of hemorrhage has been 
the use of the ligature without transfixing the pedicle. Dividing the pedicle 
too near the ligature is another source of danger, by allowing the ligature to 
slip over the stump. 

Not less than 43 per cent, of the fatal cases are credited to peritonitis. Dr. 
S. believes that the occurrence of peritonitis does not depend so much upon 
anything connected with the operation itself as upon miasmatic or contagious 
influences. Hence the greater fatality of the operation in hospitals than in 
private practice. 

The remaining causes of fatality are of minor importance and of unfrequent 
occurrence. The three causes, shock, hemorrhage, and peritonitis, represent 
upwards of 75 per cent, of the total deaths after ovariotomy; all of them, 
according to Dr. S., with proper care may be in a great measure obviated. 

Case of Defective Formation of Skin round the Umbilicus. By Albert 
Napper, Esq. — A new-born, healthy-looking boy, had on each foot a supernu- 
merary great toe ; on each hand a small additional finger, attached by a thin 
peduncle to the middle joint of the little finger. The thumbs were very broad 
with a depression down the centre, giving an appearance as if they were double. 
Some of the fingers and toes were webbed. Besides these deformities there was 
a deficiency of the integument at the umbilicus, permitting the contents of the 
abdomen to protrude into the umbilical cord to the size of a small orange. 
When the cord sloughed ofi", which it did at the margin of the true skin, it 



184 



Bibliographical Xotices. 



[July 



left only a thin transparent membrane covering the hernia, which latter daily 
increased in size until it measured seven and three-quarter inches in circumfer- 
ence. On the twelfth day after the birth of the child an attempt was made to 
close the opening at the umbilicus by a plastic operation. A circular incision 
was performed through the skin around the edge of the tumour, exposing the 
peritoneal covering. In endeavouring to separate a small portion of the mem- 
brane which firmly adhered to the peritoneum, the whole contents of the abdo- 
men, with the liver (the left lobe of which was adherent to the apex of the 
tumour) , escaped, and were returned with great difficulty. The edges of the 
wound were brought into contact by means of needles and the figure of eight 
sutures. 

The child did not appear to suffer much from pain or exhaustion. It took 
milk and water at intervals — the mother having lost her milk the previous day. 
It lay in a composed state until two o'clock the following morning, about twelve 
hours after the operation, when it died. 

The operation in this case was solely justifiable, as offering the only chance of 
saving the infant's life. From the rapid increase of the hernia there was cause 
to fear that the membrane would quickly slough and permit the escape of the 
abdominal contents. 

Fibrous Tumours of the Uterus treated by Surgical Means. By I. Baker 
Brown, F. R. C. S. — Six cases are related, with an account of the surgical treat- 
ment. These cases were, in all instances, examples of non-pedunculated tumours, 
and were destroyed by cutting into and destroying a portion of their tissue ; in 
other words, by gouging out a portion of them. But one of the cases terminated 
fatally, in consequence, as Mr. B. supposes, of the introduction of pus into the 
circulation through one of the recently divided surfaces. To avoid such an 
occurrence in future, he, as a general rule, divides the operation into two parts. 
The first, division of the os and cervix uteri; the second, performed when the 
preliminary incisions have healed, cutting into the tumour with a view to excit- 
ing in it suppuration. 

The instrument employed by Mr. B. resembles an ordinary centre-bit twisted 
spirally, with various cutting ends. There being a difficulty of fixing the tumour 
with such an instrument, Mr. P. Harper proposes one consisting of a hollow 
steel tube, with cutting knives. Within the tube is a hook capable of being 
protruded by a spring so as to seize the tumour, whilst the circular knives are 
carried through by means of a screw, actually cutting out a piece of the tumour. 
The instrument is graduated, in order that by measuring the tumour from with- 
out, a tolerably correct idea may be formed as to how far the tumour is cut into. 

On Uterine Hoimatocele. By Henry Madge, M, D. — This paper gives a very 
excellent summary of the leading facts known in relation to this form of hemor- 
rhage, gleaned chiefly from the French and German writers on the subject. A 
case is related which happened in his own practice as an example of true "retro- 
uterine hsematocele." The case terminated fatally, and the appearances on dis- 
section- are detailed, and coloured drawings given of the parts involved. 

This case was marked by certain peculiarities, which are thus indicated by Dr. 
Madge : — 

"1st. The double attack at the commencement of the illness, the slight peri- 
toneal mischief, and partial recovery, followed by the severer symptoms and 
protracted sufferings. Now, it seems quite possible that, if other conditions 
had been favourable, and the patient had not attempted to get about too sSon 
after the first attack, everything would have gone well." — 

"2d. The absence of 'tenesmus' and of 'a frequent desire to pass water.' 
The absence of tenesmus might, perhaps, receive an explanation in the proba- 
bility that the pelvic tumour did not descend low enough on the rectum to call 
that symptom into existence. With regard to the bladder, as the patient always 
kept the recumbent posture it is not difficult to understand how the neck might 
have escaped the amount of pressure necessary to cause irritability." — 

" 3d. The absence of ' fluctuation' in the tumour. The pelvic or lower portion 
of the tumour was at first hard and unyielding, and after being emptied of some 
of its contents it became rather soft and flabby." — 

"4th. The absence of arterial pulsations from enlarged arteries surrounding 



1862.] 



Transactions of the Obstetrical Society of London. 



185 



the tumour." The presence of these pulsations has often been observed, but 
not invariably. 

" 5th. The presence of phlegmasia dolens." This must be viewed as an ex- 
ceeding rare complication of uterine hsematocele. " When it does happen," Dr. 
M. thinks " it may, perhaps, be regarded as an evidence that pus in considerable 
quantity has been formed within the tumour, or that the blood contained in it 
has undergone changes of an unhealthy character, leading to phlebitis, from its 
absorption by the veins." 

Case of Difficult Position of the Heads during Tiuin Laborer. By T. Pol- 
lock, M.D.— A lady 25 years old, apparently well formed, at full term of first 
pregnancy, was seized with labour pains about 2 o'clock A.M., February 21st, 
1861. At 9 o'clock, edge of os uteri very thin, but the os itself undilated ; a 
tumour of flat bones felt presenting. By 7 o'clock P. M. the os uteri was 
dilated to the size of a half-crown piece, the presenting part descending into the 
hollow of the sacrum ; the advancing part could not be accurately made out. 
In addition to the loose flat bones, some sharp points between them, and some- 
thing resembling the coccyx, could be distinguished. Three hours later the 
finger thrust through the membranes discovered an anus, but no nates. Soon 
afterwards the right thigh and leg were brought down, and then the left. On 
making the proper traction during the pains to accomplish the delivery, Dr. P. 
found his efforts resisted by some elastic, counteracting force, causing a constant 
tendency in the body to recede so soon as the traction was discontinued. At 
length a head began gradually to pass through the vagina and out at the external 
parts ; but, much to Dr. P.'s surprise, it proved to be the head of another child. 
The head of the first child was extracted in a few minutes without much diffi- 
culty. It was found that the lower jaw of the extracted child lay across the 
lower jaw of the one unborn, so that the side of the face and head of the one 
pressed on the throat and upper part of the chest of the other. Hence, the 
first child dragged the second down, while the second held the first back, pro- 
ducing the elastic resistance referred to.. 

The second child was soon afterwards entirely expelled, and the placenta 
promptly followed. Both children — boys — were born dead. The mother did 
well, not experiencing a single unfavourable symptom. 

Presentation of Right Shoulder and Arm — Spontaneous Evolution. By 
Charles Mayo, F. E. 0. S. — After a labour of some two days, the right arm 
was found presenting, with the shoulder forced down. In consequence of the 
powerful contraction of the womb upon the child, the several attempts at turn- 
ing were unsuccessful, notwithstanding the free use of opiates and the inhalation 
of chloroform. After the lapse of several hours, the pains increased in violence, 
and the breech of the child — a boy — was expelled, speedily followed by the feet. 
An hour subsequently the head and left arm came away. The child was, of 
course, dead and exsanguine as it were from compression, excepting the right 
arrii and shoulder, which were deeply discoloured and swollen. There were 
severe after-pains and the passage of considerable clots. AVith good care and 
nursing the patient recovered slowly ; had little or no trouble with her breasts. 

On the Indications and Operations for the Induction of Premature Labour, 
and for the Acceleration of Labour. By Robert Barnes,- M. D. — In this very 
able paper Dr. Barnes has given a full history of the several means which 
have, at different times, been proposed for the artificial induction of labour, and 
for its acceleration in cases where this result is desirable and admissible. He 
has attempted an exposition of their respective and relative merits, while he 
indicates the particular cases and circumstances in which their employment 
may be resorted to with a fair prospect of their yielding beneficial results. Dr. 
Barnes' paper will be read by every one engaged in obstetrical practice with the 
deepest interest. Nowhere can there be obtained a more full and practical view 
of the subjects discussed. We regret that we shall be able to present only the 
general summary with which the paper closes. 

"It may be stated, as a general fact, that all the means employed in the in- 
duction of labour act by stimulating the spinal centre to exert itself in causing 
contraction of the uterus. Some of these agents act directly upon the spinal 
marrow, being carried thither in the blood, such as ergot of rye, borax, cinna- 



186 



Bibliographical Notices. 



[July 



mon, and other drugs. Some evoke the energies of the diastolic system, by 
stimulating various peripheral nerves, such as rectal injections, the vaginal 
douche, the colpeurynter, the carbonic acid gas douche, probably the irritation 
of the breasts by sinapisms and the air-pump, the cervical plug, whether in the 
form of sponge tent or the caoutchouc dilator, the separation of the membranes, 
the placing of a flexible bougie in the uterus, the intra-uterine injection, the 
evacuation of the liquor amnii, and galvanism. The artificial dilatation of the 
cervix, the evacuation of the liquor amnii, and the intra-uterine injection act in 
a more complicated manner, and not simply through the diastolic system. 

" Regarded from a therapeutical point of view, or in their application to 
practice, labour-inducing agents have been divided into — A. Those in which 
the integrity of the ovum is respected to the last; B. Those in which the ovum 
is interfered with, either by puncture or by partial detachment from the uterus. 
I would propose the following as a more scientific and more instructive classifi- 
cation: A. Preparatory measures ; B. Labour-provocative measures ; C. Labour- 
accelerating measures. 

" I attach great importance to this arrangement, because I believe that in the 
majority of instances it is desirable not to trust to any single agent or method, 
but to proceed in regular gradation through the stages of preparation of the 
system, and of the passages concerned in parturition, the evocation of the con- 
tractile energies of the uterus, and the acceleration of delivery, selecting such 
means in each stage as are most suitable. I believe that much danger to the 
child, and some risk to the mother, may be avoided by duly preparing the vagina 
and cervix uteri by partial dilatation and softening through the agency of the 
colpeurynter and the cervical plug. These, although they will sooner or later 
act as provocatives of labour, are chiefly efficient as dilators of the passages. 
The stage of preparation completed, we may endeavour to excite uterine con- 
traction by the vaginal douche, by rectal injections, by the partial detachment 
of the membranes from the lower part of the uterus, by the exhibition of purga- 
tives. The ergot I am inclined to discard, and know that it can be dispensed 
with. 

" If the labour hangs, if the pains are difficult to evoke, there is no necessity 
to abandon the patient to the tortures of suspense or the risk of accidents. We 
have in reserve the accelerative measures, which, the soft parts being duly pre- 
pared, place the termination of parturition entirely within our control. We 
may resort to abdominal frictions, the binder to support the uterus firmly against 
the spine, the larger uterine dilators, which are made to expand inside the cervix 
and to press, after the manner of the tense amniotic sac, upon the os internum 
uteri, the most active seat of excitation of the parturient energy ; the rupture of 
the membranes, an operation free from all objection if performed just prior to 
the natural or artificial termination of labour ; and, lastly, we have the opera- 
tion of extraction after turning by combined internal and external manipulation, 
without passing the hand into the uterus. By the judicious consecutive use of 
these means we have it in our power to terminate a labour not only on a fixed 
day, but almost at a predetermined hour, and that with a greater amount of ease 
and security to the mother and child than has been hitherto obtained." 

Substitute for Brandy in Cases of Exhaustion — Br. BruitVs " Liquid 
Essence of Beef' — Lean beef, minced and then inclosed in a jar, and subjected 
to heat for an hour or more, separates into fat, fibre, and liquid essence. The 
last, being strained off, and the fat removed by means of blotting paper, is a 
clear amber liquid, of an intensely aromatic smell and taste, very stimulating to 
the brain. It is not intended as a substitute for common beef-tea, or common 
broths and soups, but as an auxiliary to and partial substitute for brandy in all 
cases of great exhaustion or weakness, attended with cerebral depression or de- 
spondency. In the sequelae of severe and exhausting labour it is invaluable. 

Case of Idiopathic Pericarditis in a Child two years old. By A. Meadows, 
M.D. — The child had been labouring for a few days under some degree of fever- 
ishnes5, and for a few hours before death there was noticed difficulty of breath- 
ing, with a short, hacking cough, but no indications of rheumatism. Death was 
preceded by convulsions. Dissection showed inflammation of the pericardium, 



1862.] 



Transactions of the Obstetrical Society of London. 



187 



both layers of which were covered with delicate, soft flakes of recent lymph 
there was also a little fluid effused into the pericardial sac. 

New Pelvimeter. Invented by L. Lumley Earle, M. D. — The instrument is a 
very ingenious one, and in many respects is superior to any of those which 
have been heretofore suggested. From a mere description, without a drawing 
of the instrument, its construction would not be understood. 

Smallpox in Twin Foetuses. By Henry Madge, M. D. — A lady, nearly four 
months advanced in pregnancy, was attacked with varioloid ; not very severe or 
attended with any great amount of eruption. Three months afterwards she was 
delivered prematurely of twins. The first foetus expelled (a male) was the 
smaller; the other (a female), born after an interval of about fifteen minutes, 
was much larger, and in some of its parts better developed. Both were affected 
with smallpox. The largest presented the most extensive eruption of true vario- 
lous pustules, varying in size, with central depression. The male foetus had but 
six pustules on its body. They were small but perfect in form. The twins were 
born dead, but it was evident that life had not been long extinguished. 

The foregoing and other cases on record would seem, Dr. M. thinks, to 
prove : — 

" 1st. The independent liability of the foetus to disease, as shown by the different 
type of smallpox it may experience to that experienced by the mother, and in 
cases of twins in utero affected with eruptive disease, the much greater develop- 
ment of the disease in one than in the other, and, further, the possibility of only 
one being affected. 

"2d. The nature, or rather the extent of the protective power of vaccination 
in adults. 

3. The necessity or advisability of recommending all pregnant women, during 
epidemics of smallpox, or when residing in or near a district where the disease 
is prevalent, to be vaccinated or revaccinated, so as to extend the protective 
influence of vaccination to the child in utero." 

Idiopathic Pericarditis in a Child tivo and a half years old. By Henry 
Mayo, M. D. — The child died rather suddenly, without apparently suffering pain. 
The pericardium was distended with about four ounces of yellowish serum con- 
taining flakes of lymph, the heart was imbedded in a dense layer of the inflam- 
matory product. 

Case of Hydatid Mole expelled from the Uterus immediately after a Living 
Foetus and its Placenta, at about six months gestation, the hydatid growth 
being the degenerated ovum of a twin conception. By J. Hall Davis, M. D. — 
The main interest of this case is fully expressed in the title just recited of the 
paper containing its history. The remarks of Dr. Davis which accompany his 
history will fully repay an attentive perusal. 

Unusual Elongation of the Foetal Head, as a cause of difficidty in the appli- 
cation of the ordinary Obstetric Forceps, with description of a modified form 
of instrument to be used in such cases. By G. Hewitt, M. D. — Besides the 
elongation of the foetal head in its occipito-mental diameter, when it has passed 
through a pelvis of very small dimensions, or when the soft parts connected with 
it are unusually rigid, there is a change in its shape causing it to resemble rather 
the segment of a cylinder rounded off at the two extremities, than its natural 
ovoid form. This change in the foetal head renders the ordinary obstetrical 
forceps difficult of application, from a want of correspondence between their 
curve and that of the head. Dr. Hewitt has constructed an instrument adapted, 
as he believes, to such cases — a drawing of which accompanies his paper. The 
blades have a length of eight inches, and the curve an arc of a circle of fourteen 
inches in diameter. It is consequently, when locked, fitted- to inclose a larger 
oval than the ordinary English forceps. 

Inflammation of the Breast, and Milk Abscess, ivith an analysis of seventy- 
two cases. By T. W. Nunn, F. R. C.S. — Of the fifty-eight lactating cases in- 
cluded in the list of cases of mammary inflammation given by Mr. Nunn, 33, or 
between 56 and 57 per cent., occurred during the first two months after delivery; 
during the seven subsequent months up to the ninth month inclusive, only 8 
cases, or 14 per cent.; after the ninth month 17 cases, or 29 per cent. There- 
fore, if the liability to inflammation during the first two months be represented 



188 



Bibliographical Notices. 



[July 



by 4, then as far as Mr. N.'s observations go. the liability during the following 
seven months collectively falls to 1, and for the period after the ninth month 
rises to 2. This proclivity to inflammation after the ninth month must, accord- 
ing to Mr. N.. be considered as an induced proclivity, having its origin in a 
certain condition — a special cachexia — brought about by over-lactation. 

From his analysis of cases, Mr. N. has ascertained that the lower segment of 
the breast, compared to the other parts of the gland, has nearly double the 
liability to intense inflammation. 

In respect to certain points connected with the treatment of mammary inflam- 
mation and suppuration, Mr. N. presents some remarks which deserve attention. 

Poultices. — Their continued use from day to day — week after week — he con- 
demns as mischievous, and a hinderance to recovery. Under ordinary circum- 
stances he believes cotton soaked in oil. or fine lint spread with resinous oint- 
ment, to be the preferable application, both as a remedial means and from its 
being free from the disagreeableness of poulticing. 

The recumbent position Mr. N. believes may be rationally insisted upon, from 
the consideration of the fact of the more frequent occurrence of abscess in the 
lower lobes of the mammary gland. 

Belladonna as an ointment Mr. N. has employed on many occasions, but 
without any encouraging results. Several patients under its use complained of 
an increase of pain. 

As to the time proper for opening a mammary abscess, a too early and free 
incision involves excess of pain and hemorrhage, while delay beyond a certain 
point risks the sloughing of the integument and the torture"^ from spontaneous 
perforation. 

From the pain caused by any attempt to detect fluctuation by the ordinary 
manipulation in cases of inflamed mamma, Mr. N. trusts to these indications 
aff'orded to the eye alone — the protuberance and tension, the glazed surface and 
peculiar colour of the skin over the seat of the abscess. 

In the treatment of the sequelse of mammary abscess, in sinus of the breast, 
and the painful oedema so apt to remain after the more acute phenomena of in- 
flammation have subsided, a weak galvanic current, such as is aff'orded by the 
single cell apparatus in ordinary use for administering the interrupted current, 
he has found eminently beneficial. 

The three following cases are interesting and proper to be recorded, but pre- 
sent no features of particular importance in respect to diagnosis or practice. 
They are — one of Fibroid Tumour springing from the Posterior Lip of the 
Uterus, causing Complete Prolapse, and simulating Inversion of the Uterus. 
By Robert Barnes, M. D. One of Glandular Cystic Tumour of the Mamma. 
By Mr. Squire. One of Ovarian Tumour removed by Ovariotomy. By Mr. 
Spencer Wells. 

Four Cases of Ovariotomy. By "W. Tyler Smith, M. D. — The history of 
these four cases is intended as an appendix to the paper read at a former 
meeting of the society and already noticed. Three of the cases terminated 
favourably. 

Pelvic Cellulitis after Second Pregnancy, followed by Suppuration in the 
Left Groin and Left Antero-Superior Femoral Region. By N. C. Hatherly, 
M. D. — A female, twenty-nine years old, of leuco-phlegmatic appearance ; mar- 
ried for seven years; delivered of her second child September 8, 1858. Her 
labour was easy and speedy, and her getting up favourable. About five weeks 
after confinement she experienced an inability to walk from increasing stiffness 
and slight pain of left groin and left abdominal region — nothing unusual could 
be detected upon examination. In a few days afterwards there was difficult 
and somewhat painful micturition. The only constitutional symptom was a 
very antemic appearance. She was ordered poppyhead stupes with anodyne 
poultices; an occasional Dover's powder at night, with quinine and iron during 
the day. 

Dec. 5th. Slight fulness above the centre of Poupart's ligament of left side, 
of doughy feel, not easily defined ; not over tender, complains of some pelvic 
fulness. Vaginal examination showed only unusual sensitiveness of canal. 
Bigors eventually set in, and suppuration gradually advanced. Tumour in- 



1862.] Transactions of tlie Obstetrical Society of London. 189 



creased in size and became acuminated. Considerable irritative fever. Secre- 
tion of milk had gradually ceased. On the 20th, a valvular opening was made, 
which gave discharge to twelve ounces of healthy pus. On the 25th, the dis- 
charge "suddenly ceased, and pain set in in the upper left femoral region opposite 
the saphenous opening. On examination it was evident a fluid was collecting 
there ; the tumour rapidly increased, spreading downwards and laterally. Jan. 1. 
By a valvular opening in the most depending part the pus was partially evacuated. 
Ordinary treatment pursued. 5th. Symptoms of pyaemia; pulse very feeble, 
averaging 130 in a minute ; nausea and great prostration. At the end of three 
days patient began to rally — discharge decreased— daily improvement under 
use of very generous diet, alcoholic stimulants, tinct. ferri sesquichlor. and 
quinine. 

The wound healed in about a month ; at the end of twelve weeks went out 
for a drive — continued to progress steadily. Catamenia reappeared in the fourth 
month. Considerable stiffness of the hip-joint remained for nearly six months, 
when she was again able to walk about pretty well. She became again pregnant 
in about twelve months, and was safely and easily delivered of a fine child, and 
recovered without any untoward symptom. 

Historical Notes on DispIacemeTit of the U^izmpregnated Uterus as a Cause 
of Displacement of the Gravid Uterus. By J. H. Avelixg, M.D.— Dr. A. 
attempts to show that the fact of displacement of the pregnant uterus being the 
result of a similar condition of the non-pregnant organ was known to ]\[orgagni, 
and was pointed out by him more than a century ago ; and that since his time 
it has been adverted to by several members of the profession without their being 
aware, seemingly, that it had been previously noticed by any medical writer. 

When the paper was read before the society Dr. Tyler Smith remarked that, 
with the exception of Dr. Aveling's quotations from his paper of November, 
1860, those from every other writer referred entirely to the different forms of 
lateral obliquity of the pregnant uterus. Only one of the authors cited spoke at 
all of retroflexion, and that in a purely speculative manner. Dr. Smith's view, 
as opposed to that of William Hunter, that retroversion of the gravid uterus was 
caused by the impregnation and development of the previously retroverted organ, 
was published in 1856, and, he remarked, it has not been shown that this fact 
was understood by any previous writer. 

The Influence of Abnormal Parturition, Difficidt Labours, Premature Birth, 
and Asphyxia Neonatorum on the Mental and Physical Condition of the Child 
especially in Relcdion to Deformities. By W. J. Little, M.D. — The deformity 
to which Dr. L. especially refers, and an exposition of the pathology of which 
is the chief object of the present paper, consists in a tonic rigidity and ultimate 
structural shortening, of varying degrees, in a few or many of the muscles of 
the body. Both lower extremities are more or less generally involved. The 
muscles of the neck, upper extremities, and trunk, may be affected either singly 
or - several of them at one and the same time. 

Dr. L. presents in tabular form an analysis of sixty-three cases of children, of 
whom forty-seven were affected with spastic rigidity, chiefly of the muscles of 
the extremities, after abnormal or premature labour, or congenital asphyxia ; 
two with wry neck from abnormal labour or congenital asphyxia ; five with 
spastic rigidity, suspected to be from asphyxia neonatorum ; four with muscular 
debility, or paralysis from abnormal or premature labour or asphyxia ; two with 
convulsions from asphyxia at birth, followed by paralysis ; one with imbecility 
from congenital asphyxia : and one with spastic rigidity and imbecility from, it 
is supposed, embarrassed breathing ; while of one case the post-mortem exami- 
nation is given to illustrate the production of apoplectic capillary congestion in 
a child born without pelvic obstruction at birth. 

Doubtless, Dr. L. admits, there was in some of the cases he has recorded suf- 
ficient mechanical injury to the head and neck inflicted to account for whatever 
unfavourable consequences, whether these were fatal or not, may have ensued ; 
but he is convinced, the more the facts he has adduced are studied the more 
apparent will it be that a larger proportion of infants, either dead, still-born, 
apoplectic, or asphyxiated at birth, have been rendered so by interruption of 
the proper placental relation of the foetus to the mother, and non-substitution 



190 



Bibliographical Notices. 



[July 



of pulmonary respiration than from direct mechanical injury to the brain and 
spinal cord. Dissection has shown the important fact that mechanical injury 
of the foetus is not necessary for the production of intense congestion and blood 
extravasation of the serous surfaces of chest, brain, and spinal cord. 

" The other phenomenon commonly observed in difficult and abnormal partu- 
rition is that of interruption of placental respiration and circulation with non- 
substitution of pulmonary breathing and circulation. To this phenomenon 
alone, when mechanical injury or impediment has not existed, can we attribute 
the internal congestions, capillary extravasations, serous effusions which cor- 
respond with or produce the symptoms of asphyxia, suspended animation, apo- 
plexy, torpidity, tetanic spasms, convulsions of new-born children, and the spastic 
rigidity, paralysis, and idiocy subsequently witnessed." 

The paper of Dr. Little is a very valuable one ; he has handled his subject 
very fully and with great ability. It must be received as an important contribu- 
tion to infantile pathology. 

New Instruments for the Removal of Uterine Polypi, ^c. By J. Braxton 
Hicks, M. D. — The principle of these instruments is the application of annealed 
steel wire to a modification of the screw ecraseur. They may be considered as 
a decided improvement on the instruments in common use. Their construction 
and the mode of using them will be readily understood by the description given 
by Dr. H. in connection with the drawing that accompanies it. 

Polypus of the Uterus, Pendulous in the Vagina, removed by the Ecraseur. 
By G. Hewitt, M. D. — The interest of this case arises from the fact that its real 
nature had been for a long time misunderstood — it being taken for a falling of 
the womb — and the patient, in consequence, subjected to a futile and erroneous 
method of treatment. The pedicle of the polypus was found, after removal, to 
be about half an inch thick. The only inconvenience experienced by the patient 
during the removal of the tumour was just at the last, when a severe pain was 
complained of, due, as it appeared, to the traction of the pedicle on the wall of 
the uterus. There was no hemorrhage, and the patient made a perfect recovery. 

Five Cases of Ovariotomy. By I. Baker Brown, Esq., F. R. C. S. — These 
cases make a total of fourteen operations for ovariotomy performed in the 
London Surgical Home, of which ten have been successful. 

Female Bladder showing the Results of Retention of Urine after Delivery. 
By T. Spencer Wells, Esq., F. R. C. S. — The patient, 22 years of age, was de- 
livered of her first child August 20. 1860. Retention of urine ensued, to which no 
attention was paid for two days, when an unsuccessful attempt was made to pass 
the catheter. Twenty-four hours afterwards five pints of turbid, bloody urine 
were drawn off. The catheter was now introduced two or three times a day for 
some time. The urine became ammoniacal, and remained so. Involuntary 
dribbling of urine, without any fistulous opening, set in in the beginning of 
September, and, after a train of very distressing cerebral symptoms, the patient 
died October I6th. 

After death the coats of the bladder were found thickened and lying loose in the 
cavity. It contained a mass composed of the entire mucous membrane detached 
from the muscular coat, and covered on both sides with a deposit of urinary salts. 
Microscopically this mass might be described as degenerate epithelium holding 
a saline deposit. On boiling a piece of it in twenty pints of water to one ounce 
of acetic acid, much of the saline matter was dissolved, and some of the tissue 
became clear, having the appearance of smooth muscular tissue which has begun 
to degenerate by the deposit of fatty or albuminous particles in its substance. 

On Vaginismus. By J. Marion Sims, M.D. — By the term vaginismus Dr. Sims 
proposes to designate an involuntary spasmodic closure of the mouth of the vagina, 
attended with such an excessive supersensitiveness as to form a complete barrier 
to coition. The most perfect examples of vaginismus Dr. S. has met with were 
uncomplicated with inflammation. He has met, however, with cases in which 
there was a slight redness or erythema at the fourchette, just without the re- 
duplicature of the vaginal mucous membrane called the hymen. The latter is 
usually thick and voluminous, and when the finger is passed into the vagina its 
free edge often feels as resistant as if bound with a fine cord or wire. The 
gentlest touch with the finger, or even a feather, produces the most excruciating 



1862.] Transactions of the Obstetrical Society of London. 191 



agony. The sensitiveness which is at all parts of the vaginal outlet, is especially 
pronounced at the meatus urinarius and on each side of it, still more so on the 
outer face of the hymen, near the orifice of the vulvo-vaginal gland, and to the 
greatest extent just in the sulcus or reduplication from the vulval orifice. In all 
cases the mere spasm of the sphincter is painful, and in many cases the sphincter 
ani feels almost as hard as a ball of ivory. The spasm is pathognomonic of the 
disease, the supersensitiveness diagnostic. 

The treatment proposed by Dr. S. consists in the removal of the hymen, the 
incision of the vaginal orifice, and its subsequent dilatation. For a description 
of the operation and of the instrument employed by him as a dilator, we must 
refer to the paper itself. 

Case of a Patient who in Eighteen Pregnancies gave Birth to only Seven 
Ldving Children, the eleven others having been expelled dead at various periods 
of Gestation. By W. Newman, M. D. The circumstances connected with this 
case would seem to point very clearly to a cause of death in the foetus that has 
been too frequently overlooked, namely a want of formative power on the part 
of the mother, which in the case detailed increased with each succeeding preg- 
nancy. 

Case of Abortion : Retention of Ovum within the Uterus, and Growth of 
Membranes for a Period of Five Months after the Death of the Foetus. By 
G. Hewitt, M. D. 

Knot on Funis, in a Case in ivhich the Foetus ivas horn dead. By W. 
Sankey, Esq. — The titles of these two papers explain fully the leading character 
of the cases described in them. 

Instrument for the Removal of Polypi of the Uterus. By Tyler Smith, M. D. 
— It consists of a rod and winch with double canula, made sufficiently strong to 
carry a single or stranded copper or iron wire, and bear tension enough to cut 
through the neck of a polypus at once. 

Case of United Children, or Double Monstrosity. By Henry Hawks, 
L. R. C. P. Ed. — The heads of the children were covered with hair. Each of 
them possessed two arms and two legs, with perfect fingers and toes. There 
was a single thorax, in which were two lungs, one pericardium, and one heart. The 
abdomen was common to both children, with a single liver and spleen, one set 
of intestines, and two kidneys. There were two urinary bladders. The union 
of the child was from the top of the sternum to the umbilicus. The length of 
one was eighteen inches, of the other seventeen inches ; they measured eighteen 
and a half inches round the shoulders ; weight sixteen and a half pounds. 
They appear to have been both females. 

Case of Peritonitis caused by Escape of Pus or Putrilage from the Fallopian 
Tube into the Abdominal Cavity, folloioing an Abortion artificially induced. 
By Robert Barnes, M. D. — This case, with the introductory notice of cases of 
a similar character, is replete with interest. It will not admit well of abridge- 
me-nt, and this article has been already extended to too great a length to admit 
of its insertion entire. 

A very valuable practical paper is presented by Mr. Robert Ellis, on Cau- 
terization by Electric Heat in certain Diseases of Women, to which we would 
call special attention. The subject is a most interesting one, and is ably 
handl'ed by Mr. Ellis. 

Case of Inguinal Hernia of the Right Ovary successfully removed. By A. 
Meadows, M. D. — Cases of a similar character are extremely rare. The present 
one was among the first in which an operation was attempted. The operation was 
in all respects successful. It is suggested that, had the patient been seen when the 
accident first occurred, or at least after the first menstrual period, when severe 
pain was experienced in the tumour, its nature might even then have been diag- 
nosed, and its replacement happily effected either by the taxis or by operation. 

The volume closes by the history of a Case of Congenital Inflammatory Dis- 
ease of the Skin of the Head and Upper Part of the Body of an Eight Months' 
Foetus, ivith Exudation of Plastic Lymph. By G. D. Gibbs, M.D. 

D. F. C. 



192 



Bibliographical Notices. 



[July 



Art. XXI. — Public Health in Relation to Air and Water. By W. T. Gaird- 
NER, M. D., Fellow of the Royal College of Physicians, Edinburgh; Physi- 
cian to the Roval Infirmary, and Lecturer on the Practice of ^Medicine. 12nio. 
pp. 369. Edinburgh, 1862. 

The present volume embraces the substance of a course of lectures delivered 
during the summer of 1861, to an audience composed partly of students of medi- 
cine, and partly of persons otherwise interested in the subject of public health. 
These lectures were undertaken by Dr. Grairdner, mainly to communicate some 
of the elementary principles of modern sanitary science to those whom he had 
instructed' in the science and the art of healing, in order to complete, as he con- 
ceives ought to be completed, the cycle of sciences on which the art of healing 
rests ; while, at the same time, he endeavoured to establish a cordial understand- 
ing between the medical profession and the community at large on the subject 
of public hygiene — to claim for the physician the due influence which he has a 
right to exercise in relation to all sanitary reforms, from his legitimate position 
as a conservator of the public health, and the labours he has already performed 
in respect to its maintenance and increase, and, finally, to effect something 
towards establishing the claim which the study of public hygiene presents as a 
department of medical science. 

Although the arrangement of these lectures and the manner, generally, in 
which the subjects embraced in them are handled, may be amenable to criti- 
cism, nevertheless, the principles set forth by the lecturer are unquestionably 
sound, while his hygienic deductions from those principles are correct and 
practical throughout, and of universal applicability. His teachings are based 
chiefly upon facts derived from the rich mine furnished by the Registrar General's 
reports and those of the Health of Towns Commissions. By a careful collation 
of the statistics contained in these reports, compared with those derived from 
observations upon the same points collected in some of the larger continental 
cities, we are enabled to arrive at certain positive data that have caused modern 
sanitary science to pass out from ''the stage of the hypothetical, and become a 
strictly inductive and closely reasoned branch of knowledge, resting upon a solid 
basis of experience." 

Dr. Gairdner was induced to make the consideration of air and water as sani- 
tary agents, the leading subject of his lectures on public health, from the fact 
that these two essential elements of life, when contaminated with the effete pro- 
ducts of the human body, or with organic matter in a state of decomposition, 
may be denominated the two factors of almost all endemic and epidemic diseases 
as well also of a large number of chronic maladies. Hence, in the manage- 
ment of the supply of pure air and pure water is included almost the entire sani- 
tary code. 

"When," as the lecturer aptly remarks, "you get air and water systematically 
purified, you have not only begun, but you have advanced far in the work of 
sanitary reform. You have, indeed, done the greater part of all that you can 
do in the way of legal interference in regard to public health. It is, therefore, 
very important you should thoroughly grasp the ideas connected with the puri- 
fication of air and water. The health and the morals of the population here 
hang by the same thread ; for though 1 am not about to argue that men are moral 
or immoral simply as the creatures of circumstances, yet there can be very little 
doubt that the physical circumstances in which men are placed often dominate 
to a vast extent their moral health. They do so at all events to this extent, 
that without a certain degree of purity of air. water, and person (and the last is 
the result of the other two), self-respect, and respect for others, which are the 
foundation of the moral code as between man and man. become impossible. 
And, therefore, literally and truly, as was said long ago in the way of proverb, 
'cleanliness is next to godliness.' Nay, even godliness itself is not a little de- 
pendent upon cleanliness when you speak of large numbers of men," 

As the main physiological elements of health Dr. G. enumerates pure air. pure 
wholesome water, plenty of light and warmth, good food, sufficient and proper 



1862.] 



Gairdner, Public Health. 



193 



clothing, a comfortable home, fitting occ-apation — including in the case of artisans 
and mechanics a wholesome condition of workshops — a proper relation between 
the sexes — the right cultivation of domestic habits, and of the natural social 
affections ; and, finally, a sufficient amount of relaxation and amusement at 
proper intervals, including, under the head of relaxation, the important item of 
absolute rest and sleep. By quotations from the English health reports Dr. G. 
has shown the important relation which these diS'erent conditions of health bear 
to one another, and, especially, the immense extent to which "the comfort of 
the home and of the workshop, as respects the single first element of health, 
proper ventilation, is found to enter into all the more complex developments of 
the other essential conditions of health, so that without proper ventilation, and 
the closely allied conditions of good drainage and sewerage, it is impossible to 
expect that any of the other great vital necessities can be properly or even 
moderately well attended to." 

Another reason why, in treating of public health, Dr. G. considers that our 
chief attention should be directed to a consideration of air and water as sani- 
tary agents, is founded upon the circumstance that, to secure to the whole com- 
munity and to each individual composing it, a constant supply of these first 
reciuisites of health, and in a state of as perfect purity as can be attained, legal 
interposition is not only perfectly justifiable but is actually demanded. 

" Our food, our clothing, our dwellings — that is to say, the walls and the fur- 
niture of them — -are personally ours," the lecturer remarks, "in a sense in which 
air and water are not. Air and water belong to no man, they belong to all men. 
We have all a right to use them, but we cannot confine the use of them, or even 
of any portion of them, to ourselves ; and just because God has given them in 
free unstinted measure, as a common gift, to all the inhabitants of the earth 
without distinction, just because of this we have all a right to use them, while 
none of us has a right to abuse them. And, furthermore, each one of us, as an 
individual, and the community as representing the whole mass of individuals, has 
an indefeasible right to see that no individual of the community does abuse them 
to the possible injury of the rest." 

From these premises Dr. G. deduces the right of authoritative interference, if 
necessary, in regard to air and water. It may be a question of expediency or of 
possibility in any particular case as to how far we can carry that right ; but we 
have, he insists, in theory the right, as a community, to interfere to the full 
extent necessary to preserve the greatest attainable purity of air and water to 
every member of the community. 

Dr. Gairdner believes that, from what we know of the history of those dis- 
eases which are called epidemic or pestilence, we have a right to conclude their 
occurrence is not a necessary or unavoidable thing, but a thing which, by care 
and attention to the conditions of health, we can get rid of to a great extent, if 
not entirely. We have a right, he maintains, to believe that pestilence may be 
rooted out absolutely from the entire community, because we find that in prac- 
tice many epidemic diseases have been entirely rooted out in respect to large 
sections of the community, by attention simply to the purity of air and water : 
and, consequently, that we should not relax our eff"orts until we have got rid 
of epidemic diseases entirely. He believes that we are, to a certain extent, 
justified by facts in looking upon the mere existence of such diseases — not, per- 
haps, in every case, but certainly in the great majority of cases — as the evidence 
— plain and undeniable evidence — of a violated law ; a law which requires of us 
to abstain from everything that is calculated to detract from the purity and 
free circulation of air and water. Impurity and stagnation of these primary 
elements of healthful existence being, in his estimate, the main predisposing 
cause of all those diseases commonly known as epidemics. 

Mere impurity and stagnation of air and water can scarcely, we think, be 
viewed as the generating or efficient cause of all afi'ections of an endemic or epi- 
demic character. Many of these owe their origin to a certain morbific some- 
thing connected with the atmosphere at particular periods, and which more or 
less gradually extends itself in certain directions and over different extents of 
the earth's surface. Of this morbific principle we know nothing, its presence 
being' shown only bv the pestilence to which it gives rise. Now. though it m 
jS'O. LXXXYIL— July 1862. 13 



194 



Bibliographical ^^'otices. 



[July 



very certain that it may be invited, as it were, to a particular locality or district, 
and the intensity of its action augmented by certain appreciable conditions of 
atmosphere, including its stagnation and vitiation, yet, in numerous instances, 
the influence of the morbific poison will be experienced when the movements of 
the air and water are unrestrained and no sources of vitiation in respect to either 
can be detected. As Dr. G. well remarks — 

''Neither a bad smell, as such, nor sulphuretted hydrogen, as such, nor car- 
bonic acid, as such, contains the special poisons which we have to fear particu- 
larly as the sources of epidemic disease. But all of these are, to a certain extent, 
indications, beneficent, providential warnings plainly given us — to view the 
matter from the aspect of final causes — to bring before our very senses the cir- 
cumstances under which dangerous poisons may perchance be present. Such 
poisons may not be present in ninety-nine cases out of a hundred, where the air 
is manifestly impure to the senses, or saturated with gases which are the known 
products of organic decomposition, but in the hundredth case you may have a 
true morbid poison there present, and then it is a most deadly poison ; and this 
we can certainly say, that if we had not had the excess of carbonic acid, nor the 
sulphuretted hydrogen, nor the bad smell, in all probability we should not have 
had the dangerous element present either. The same law applies to water. 
AVater, as I showed you in my first lecture, contains, in some cases,, those morbid 
poisons which we have to fear as the causes of disease. It is the medium, for 
instance, in some cases, of that dreadful poison of epidemic cholera ; and of some 
other diseases it is probably the principal medium. But we can study the pro- 
cess most conveniently, perhaps, in the case of the smallpox pustule, which 
contains a very terrific poison in small bulk, and so constituted as to act upon 
the fluids of the human body by becoming dissolved in water ; or, again, in the 
cowpox pustule, which is really only another, though a far more benign form of 
smallpox. In these cases we have the whole of the facts in relation to a most 
virulent and active source of disease under our daily observation and control. 
We know of a certainty, in the little, seemingly insignificant, droplet of watery 
fluid inserted into the arm by the inoculator,.is inclosed the specific poison of 
smallpox or cowpox. We know, therefore, that such poisons exist, that they 
are specific poisons which cannot be chemically analyzed or mechanically weighed 
or measured; that an infinitesimally small amoant of them, in fact, will produce 
the disease. We know that they may possibly exist wherever water or air con- 
tain certain organic impurities, with which the specific secretions or exhalations 
of persons suff'ering under disease may have been in contact. We know, on the 
other hand, that these poisons cannot exist where there are no such impurities ; 
that is nearly all we know about them. And, therefore, although you may not 
be able to demonstrate that a particular organic impurity in water is poisonous, 
although you may even be able to bring a strong body of evidence to show that 
it is not poisonous ; yet, wherever you have a considerable amount of organic 
impurity habitually present in water, as in air, depend upon it you have some of 
the conditions in which these peculiarly evanescent and dangerous poisons may 
possibly lurk unseen." 

To impurity of air and water Dr. G. refers, not only as the chief predisposing 
cause of epidemic diseases, but as causes, to a large extent, of other diseases. 
In proof of this latter position the lecturer confines himself to the etiology of 
two diseases, pulmonary consumption and infantile convulsions. The influence 
of impure and stagnant air as a cause of convulsions and other serious affections, 
by which, annually, in all our larger cities, a very large amount of mortality 
among infants is caused, is so well understood by the medical profession in this 
country, that it is only necessary here merely to advert to it. The dependence 
of pulmonary tuberculosis upon a foul and stagnant atmosphere is, however, not 
so generally recognized. That, in conjunction with the want of a due amount 
of active exercise, and more especially with a constrained position of body long 
continued, it may play an important part in the etiology of tuberculosis is, how- 
ever, by no means an improbable supposition. 

In the essay of Dr. Baly on the mortality of prisons [Med.-Cliirurg. Trans., 
1845); in the report of the commissioners on the health of the army, appointed 
after the Crimean war; and in the reports of the Consumption Hospital at Bromp- 



1862.] 



Gairdner, Public Health. 



195 



ton, will be found a series of facts showing that a want of ventilation of houses, 
workshops, and unquestionably, in many instances, of schools also, may be fairly 
set down as contributing towards the production of a large amount of the mor- 
tality incident to pulmonary phthisis and the other forms of tubercular disease. 
In 1824, Dr. Alison, in a paper published in the first volume of the Edinburgh 
Medico- Chirurg. Transactions, endeavoured to prove that confinement, and 
want of exercise, rather than cold or deficient nourishment, are the causes of 
tubercular disease. The dependence of the latter upon vitiated air was also 
maintained by Baudelocque in his treatise on scrofula, published in 1834; and 
the same has been recently urged by Dr. M'Cormac, of Belfast, Ireland. Mr. 
Toynbee has observed that, among the working classes of London, while scrofu- 
lous and tubercular diseases are the result of ill-ventilated dwellings and work- 
shops, in connection with destitution and an imperfect supply of food, gouty and 
rheumatic disorders prevail among those who are driven by the physical ex- 
haustion caused by working in an impure air to the use of alcoholic stimulants. 

In his evidence before the Health of Towns Commission, Dr. Guy stated that 
he had investigated with great care the circumstances attending the derange- 
ment of health in 320 of the journeymen printers of London. After careful 
inquiry he was enabled to arrange them in three classes nearly equal in numbers. 
In the first class, the men habitually respired in their workshops an atmosphere 
of less than 500 cubic feet of air per man ; in the second class, the quantity was 
between 500 and 600 cubic feet ; in the third class, it was over 600 cubic feet. 
Taking as his guides, two of the leading symptoms of consumption, which could 
be easily detected by questions, he found that the difference between the first 
and last of the above classes was as follows : Of the first, or luorst off" class, as 
respects air, 12|- per cent, had spat up blood, and a like proportion had been, 
subject to catarrh ; while, of the third or test off" class, only 4 per cent, had 
suffered from spitting of blood, and only 2 per cent, from catarrh. The medium 
class of workmen occupied also a similar medium position with respect to both 
these unfavourable symptoms. In connection with the foregoing facts, Dr. G. 
remarks : As the diff'erences are considerable between the comparative fre- 
quency of scrofulous diseases, and of internal tubercular affections in diff'erent 
localities, there must in all probability be some unknown specific cause of each^ 
to the activity of which a defective air supply is an essential, or nearly essential 
condition. In connection with this obscure subject, it should not be overlooked, 
that the contagious or infectious character of consumption has at different times 
been a popular belief, and has also found favour with many good medical authori- 
ties, although more usually set aside as deficient in evidence. Without wishing 
to dogmatize on the subject, I think it must be conceded that the frequent occur 
rence of the disease in connection with bad ventilation, is rather in favour of the 
view of some degree of contagious property, and ought to inspire reasonable 
caution as regards the too close approximation of the sick to the healthy. A 
pure air by day and by night, is the only safeguard against this danger, if it 
really exist, and considering the lamentably frequent instances of the wide diffu- 
sion of the disease in families — though this does not necessarily presuppose 
contagion — no precaution should be neglected that is consistent with the humane 
and attentive nursing of the sick." 

The volume before us comprises seven lectures. The first, or introductory, 
refers to the care of the public health as a medical function. The attention 
paid to it in early times ; the minute sanitary requirements of the Jewish cere- 
monial law — a law which may in very many and important particulars be made 
even at the present day our exemplar and our guide. The Roman sanitary 
legislation is also cursorily noticed. The neglect of almost everything relating 
to hygiene in the middle ages is commented on, and its consequences pointed 
out, by a reference to the widespread contagious and other epidemics, which so 
repeatedly desolated, at intervals, during this period, most of the large cities — 
cities which appear to have been built and governed with the express intent of 
excluding as much as possible the circulation of the air, the entrance of the 
sun's rays, of crowding in as small a space as possible the inhabitants, and of 
surrounding them with all manner of uncleanliness. The lecturer presents then 
a rapid but most instructive sketch of the gradual and partial reform which was 



196 



Bibliographical Notices. 



[July 



at length brought about through the more careful study of certain epidemic 
diseases by a few zealous i^hysicians, and the reyelations made by Howard and 
others in respect to the condition of the jails, hospitals, and lazar-houses of 
England ; until, in the present century and within the last thirty years, the 
public mind being strongly and universally directed to the origin and suppres- 
sion of pestilential diseases, through the labours of Mr. Chadwick and his col- 
leagues, a series of investigations were instituted and eflfectually carried out to 
determine from actual observation the sanitary condition of the labouring popu- 
lation, and of the principal cities of Great Britain. From the results of these 
movements, taken in connection with the body of vital statistics, contained in 
the reports of the English Registrar-General. Dr. Farr, have been developed the 
leading data upon which alone must be based a successful system of sauitery 
organization, public as well as private, having for its object the security and 
augmentation of the health of all classes of society, in every community, and the 
prevention of pestilential diseases in their midst. 

The second lecture takes up the subject of public health, in connection with 
air and water as sanitary agents. In this portion of the course we are pre- 
sented with some general views in relation to the causes of the deterioration 
from the requisite purity of these two essential elements of health, and the 
natural processes by which that purity is restored and maintained. 

The impurity of the air and water in particular houses, cities, and other locali- 
ties, is no doubt chiefly due to overcrowding, and to defective ventilation and 
drainage. In consequence of such neglect, the impurities given off by the human 
body in the course of its regular physiological functions, or generated during the 
various processes instituted by man for his personal and domestic comfort, and 
in the course of various industrial pursuits, by the neglect of cleanliness, also, 
and the consequent retention of organic remains in a state of decomposition 
about his person or premises, must necessarily be allowed to accumulate within 
a comparatively small compass. With perfect ventilation and adequate drain- 
age, these impurities would have been speedily dispersed and made to undergo 
by means of the subtle chemistry of nature such changes as were required to 
render them supporters, instead of disturbers or destroyers of vitality. 

To secure adequate ventilation and drainage would appear, therefore, to be 
among the primary means to be instituted for the maintenance of health in the 
individual and the warding off of pestilential disease from communities. Such 
is certainly the case, whenever by ventilation we introduce a constant current 
of pure air in and around our dwellings. For we are to recollect that the very 
air which is caused to flow into our dwellings, our workshops, our school rooms, 
our churches and other places of public resort, may be itself the means of com- 
municating disease, from the impurities it has imbibed in its passage over places 
in our vicinity where there exist sources of morbific emanations. A city, or 
village or tract of country may be rendered eminently unhealthy if it be so 
situated that the prevailing winds traverse an extensive malarious district, or 
one abounding in marshes or large collections of stagnant water. So, also, 
drainage and the removal of every species of obstruction in our streams and 
water-courses generally, however fully accomplished, though always productive 
of beneficial effects in a sanitary point of view, will not alone always supply us 
3?rith pure potable water. The sources of the water may be such as to cause it 
to be impregnated with saline or other ingredients, or these may be poured into 
it along its course in such quantities as to render it unfit for use as a drink. 

The subject of impure air and overcrowding is very well treated of in the third 
lecture. Its influence as a sanitary agent is amply illustrated by frequent refer- 
ence to the facts developed in the reports of the Health of Towns Commission, 
ec«pecially those in regard to Liverpool. 

In the conclusion of this lecture Dr. G. makes the following highly important 
remarks : — 

" The great evil that we have to fix upon, as a guide to the purification of the 
air, is. the fact of epidemic disease in connection with overcrowding. But, 
although that is the form we must chiefly fix upon, I am not at all sure that 
epidemic disease is the form of evil that does the most damage to the public 
health. A vast amount of mischief is caused, no doubt, by the spread of such 



1862.] 



Gairdner, Public Health. 



197 



a disease as typhus fever, which too often cuts off the head of a family. A 
somewhat less, but still a considerable amount of evil is produced by the diseases 
of measles and scarlet fever, which often destroy the children of a family, and in 
many cases, where the children are not destroyed, leave them with a weakened 
vitality, which lessens their value and usefulness as members of society all the 
rest of their lives. But, I am not sure that even a greater amount of physical 
deterioration is not produced by the tendency of overcrowded apartments, and 
a deficiency of free ventilation, to sow the seeds of tubercular disease, and par- 
ticularly of pulmonary diseases of all kinds, Knowing, as we do, that from a 
seventh to an eighth over all England, and probably from a sixth to a fifth, or 
even a fourth, of the population that die in some of the great towns, fall victims 
to some form or other of tubercular disease — whether this does not present even 
a more terrible picture than the other, of the cousequences of deficient ventila- 
tion. In the case of consumption, alone, we are dealing with a disease which 
annually destroys more than 50,000 persons in England and Wales, and we are 
very sure that a large proportion of this immense mortality is an avoidable 
mortality, inasmuch as we know to what an extent it occurs in close and un- 
wholesome houses, workshops, schools, and places of public resort. If the 
prevalence of this one disease could be reduced, say by one-half, or even one- 
third, through systematic attention to the principles of public health, it would 
be far more than worth, in mere money value, a sum equal to the interest of the 
national debt." 

The subject of the next two lectures — the fourth and fifth — is water in refer- 
ence to public health. The necessity of an adequate supply of water for culi- 
nary purposes, for the maintenance of personal and domestic cleanliness, and as 
a beverage, is pointed out, and the importance of the supply being of water of 
the purest quality that can be obtained, especially in reference to its use in the 
preparation of our food, and still more so as our common drink, is strongly 
enforced by Dr. G. 

In the fourth lecture, which treats of the water supply and the injury which 
must necessarily result when this is deficient, there are announced many general 
truths which are applicable alike to every community, nevertheless, most of the 
facts, arguments, and illustrations of the lecturer, under this head, have more 
especial reference to the water supply of Edinburgh and London. They are but 
partially applicable to the leading cities of the United States, in nearly, if not 
all of which an ample supply of water is furnished, and at so small an annual 
expense, that even the poorest individual or family may avail himself of it, 
without stint, for every purpose for which it is required. 

The subject of impure water is discussed in lecture five. The causes by which 
water may be rendered impure, and thus unfit for the use of man, are numerous. 
The great majority of them it is within our power entirely to remove. It is 
chiefly those causes through which the water becomes loaded with organic 
remains in a state of decomposition that render it the most prejudicial to health. 
Hence the well-founded prejudice against the use of the water of marshes, shal- 
low ponds, and, indeed, against the use of water that, in any situation, has re- 
mained for a long time stagnant. Hence the unwholesomeness — an unwhole- 
someness frequently but little suspected — of water that has passed through a 
soil which has become strongly impregnated with decomposing animal remains, 
and exuvijE ; a soil too often to be met with in the midst of large cities with 
their numerous ill-constructed sewers, cesspools, and graveyards. 

The principal circumstances under which water becomes dangerously impure, 
are enumerated by Dr. G. as follows : First. When a neighbourhood, situated 
at a lower level than the other portions of the city, town, or village, to which it 
appertains, receives the entire drainage of the higher grounds. Second. When 
the drainage is defective, or the drains and common sewers are so constructed 
as to leak into the subsoil, or to become choked, so as to cause their frequent 
overflow. Third. When the drainage is into a river or stream from whence, 
and within the poisonous influence of the sewage, comes the water supply of the 
people. Fourth. When there is no proper or adequate system of drainage, 
impurities being allowed to accumulate upon the surface and soak into the soil, 
while the leakage from cesspools is widely diffused throughout the subsoil so as 



198 



Bibliographical IS'otices. 



[July 



to contaminate the watei' courses and wells from which the water supply is 
obtained. 

The lecturer adduces many striking facts, proving most clearly the influence 
of impure water in the production of endemic and epidemic diseases — of cholera, 
dysentery, and various other maladies of a very serious and deadly character. 
He strongly enforces the view which refers the dissemination of cholera chiefly 
to the use of water impregnated with a particular poisonous matter. With the 
view of establishing the correctness of this view, he attempts to show by facts, 
the accuracy of which cannot be disputed, that cholera is a disease of low levels, 
but not of all low places and low levels even within the geographical limits in- 
vaded epidemically by the disease, thus showing that other and opposite tenden- 
cies are sometimes at work in particular localities. In respect to cholera, he 
remarks : — 

" We want a cause of disease which is consistent with its communication from 
man to man, and along the great lines of human intercourse, yet which does not 
imply a large amount of contagious or infectious power, in the ordinary sense of 
a disease which is ' catching,' through the breath or exhalations of the skin ; a 
contagion, in short, which allows of your approaching the sick, or remaining in 
the same room with them, with little danger as compared with the case of fever 
or of smallpox. All these conditions are met by the theory of a poison commu- 
nicated from the sick to the healthy, but communicated chiefly through water, 
and only to a comparatively slight extent through the air. This, accordingly, 
is the modern theory of the diffusion of cholera. We have come to believe that 
it is, indeed, as the Hindoo supposes, a disease dependent upon poisoned water, 
only the poison is not an extraneous one, but is generated and reproduced in and 
by the bodies of the sick." 

The subject of drainage and sewerage are treated of in a very general man- 
ner in the sixth lecture. In the seventh is discussed at some length the subject 
of sanitary organization. That is an organization having for its sole object the 
promotion of the public health of the community generally, by devising and 
procuring such legal enactments for the security of the public health as may be 
found necessary and proper; by co-operating with the State and municipal ofiBcers 
in the enforcement of the measures which these enactments provide for; by 
securing to every neighbourhood, family, and individual, in the community, a 
constant and adequate supply of pure air and pure water ; by communicating, 
as far as is possible, to every class of the people, advice and instruction in regard 
to such a mode of living, within their means, as shall the most certainly conduce 
to their health and well-being ; and to place within the reach of all the means 
for regular bathing, proper, economical, and wholesome cookery, and the accom- 
modations furnished by improved boarding, and tenement houses. 

The leading facts and arguments employed by Pr. G. in the illustration and 
enforcement of the principles laid down by him in these concluding lectures, are 
derived almost exclusively from the condition of the people in the different cities, 
towns, and villages of Great Britain. While his reformatory measures, and the 
manner in which he proposes to secure their accomplishment, have reference 
mainly to the poor and labouring classes of that kingdom, they will, nevertheless, 
be found, to a very great extent, applicable also to the condition of things 
which prevails amid the several communities of the United States. The discus- 
sion of the subjects referred to by Dr. G. presents much that is highly instructive. 
His fifth and sixth lectures, equally with those which precede, deserve a careful 
study on the part of every one interested in the etiology of disease, and who 
would desire to promote the inauguration and enforcement of measures adapted 
to remove the causes of endemic maladies. Although these measures cannot 
effect as much in respect to those maladies which prevail epidemically, they 
will be found, at least, to disarm them of their malignancy, and circumscribe to 
a great extent their prevalence. 



subjects of deep interest to the sanitary reformer, and a familiarity with which 
is calculated to promote the cause of public health. 

We may here remark that the volume before us does not contain all the lec- 
tures which composed the course as actually delivered by Dr. G. Five lectures 




appended in reference to 



1862.] 



Gairdner, Public Health. 



199 



are omitted from the fact of their being exclusively devoted to the mere technical 
and scientific consideration of the various circumstances bearing on the death- 
rate, and on the application of the Registrar-CSreneral's data to sanitary purposes. 

Notwithstanding the length to which we have already extended our notice of 
the lectures of Dr. Grardner, we cannot refrain from laying before our readers 
an extract or two from the recapitulation with which the sixth lecture concludes. 
They speak most solemn truths in respect to the important subject of public 
hygiene, which cannot be too often urged upon the attention not merely of 
physicians, but of our State and municipal legislators, and of the citizens 
generally. 

"• I cannot close this lecture, and with it the review of the consequences of our 
neglect of the first elements of public health, without pointing out to you, once 
more, how many of the other evils that affect the lower classes of our population 
are connected more or less directly with the want of a sufficiency of pure air and 
water in the home. ^ ^ * Pure air and water, then, are necessary to much more 
than health and mere physical comfort ; they involve in themselves inextricably 
the first elements of almost all the social virtues, because, where you cannot 
have cleanliness, you cannot long have either self-respect or respect for others, 
without which none of the social and practical virtues can get soil, so to speak, 
to take root. And, accordingly, it is the inevitable consequence of leaving a 
large population in a permanently impure and unclean state, that habits are 
created destructive of the social virtues ; and in the course of a few generations 
the very germs of these virtues, the germs of morality and decency, of all the 
little charities and graces of social life, and, finally, of all the attributes that 
lift man above the brutes, die out in the infected atmosphere of physical de- 
gradation." 

The picture which Dr. G. here paints is, as he remarks, a hideous one ; it will, 
nevertheless, be found to delineate, with but very little exaggeration in any one 
of its features, the actual condition of the lowest classes in some of our great 
cities. Nor can it be considered a mere hypothetical supposition to refer the 
origin of all the revolting features depicted to the degrading influence conse- 
quent upon a deprivation of the two principles of health— public as well as 
private — air and water, pure in quality and ample in quantity. Proof conclu 
sive in support of the correctness of the views so ably set forth by the lecturer 
can be furnished from the annals of the degraded classes of our own cities, but 
more especially of the cities of Europe, where the supply of air and water is 
cut off from the poor to a much greater extent than it is with us, as well by 
their own improvidence as by the desire for gain irrespective of everything else, 
on the part of a certain, and, unfortunately, too numerous class of property 
holders. In a later part of his recapitulation, Dr G. uses the following impres- 
sive language : — 

"Observe, then, the complicated effects of physical impurity, or even the 
neglect of comfort in the home. Besides the bad efiects upon the health directly, 
it creates a lowered tone of feeling and of personal delicacy: in the worst cases, 
it almost obliterates the sense of shame, and leads to an indiscriminate and 
shockingly depraved commerce of the sexes. When the evil falls short of this, 
it makes the home untidy and wretched, at first, in spite even of the struggle 
after better things. Then the character of the household deteriorates ; the 
woman gradually loses her feeling of satisfaction in her home ; she feels that it 
is impossible for her to make it, what she ought, an attraction and a pleasure to 
her husband. Then quarrels occur, and the liome becomes unbearable at times ; 
finally, the evil extends to the husband, in a far more pernicious shape still, 
making him permanently careless and negligent, unfond of his home, unfond of 
his wife and of his children, and in too many instances fond of some deleterious 
substitute for the enjoyments of home and the tranquillizing influences of a 
virtuous family life. It is here, beyond all doubt, I believe, that we must look for 
the source of much of the drunkenness and other vices of the labouring classes." 

This relationship between public and domestic hygiene — with the real com- 
forts which follow its due enforcement — with the improved moral deportment and 
happiness of the labouring classes, has, heretofore, been too much overlooked. 
It is well founded, nevertheless, and furnishes an additional and very weighty 



200 



Bibliographical Notices. 



[July 



argument in favour of a careful study of everything having for its object the pro- 
motion to the greatest and widest extent of the public health. 

''Need it be said," inquires Dr. G,, "that the terrible evils of a disturbed 
family relation, and a disordered home, tell with fearful force upon the health, 
the morals, the habits, and the lives of the rising generation, and especially of 
the very young children? It would be marvellous, indeed, if it were not so. 
I should not know what to believe. If I found that a disorderly home did not 
tell upon those exquisitely tender, delicate lives, which, as I showed in a 
former lecture, are three or four, or five or six, in some cases even ten times, 
more subject to destruction than are the lives of members of the community at 
other ages. But we are not left to speculate on this matter. We know, as a 
fact, that the lives of young infants are not only very fragile, but are actually 
sacrificed to an enormous extent wherever the home is neglected. In a former 
part of this course, I showed that the variation in the death-rate of very young 
infants is not less than enormous, as compared with that of adults ; so that 
while the difference between the healthiest and the most unhealthy district of 
England, as respects the death-rate of the whole population, is not more than 
about 15 in 1,000 living, the diff"erence in respect to children under five years is 
nearly 90 in 1,000, and the difference as to children under one year is, I have 
reason to believe, more than 200 in 1.000 liviug. There are, indeed, not a few 
places in which, counting over large numbers of the population, the children 
are thus mismanaged: Where the domestic relations of the populatiou. taken 
as a whole, are so bad that not less than a third, probably indeed much more 
in some places, of all the children born fall victims to disease, or are in some 
way or other destroyed before they are even one year old — before their little 
limbs have learned to walk, or their tongues to speak, and while they yet are, or 
ought to be, drawing their food from the breasts of their too careless, or perhaps 
yet more unhappy mothers. I hardly know a fact in the long story of human 
guilt and misery more deeply impressive than this." * * * 

Many more extracts might be made, showing how intimately health and pros- 
perity, and civilization — all things, indeed, which concern the happiness of indi- 
viduals and communities — are connected ; that it is not less the duty than the 
interest of the community to see that the means of personal and domestic clean- 
liness, the free use of the commonest and most indispensable of God's gifts, air 
and water, are brought within the reach of all, and that they are, as far as prac- 
ticable, properly applied. But we refrain; we at the same time recommend the 
volume of Dr. G. to the careful study of every one. The author has presented 
in a plain and forcible manner the important subjects of which he treats, and 
has adduced a large amount of facts in illustration of their true character and 
of the correctness and cogency of the arguments by which he has endeavoured 
to enlist in their behalf the public mind and organized co-operation. It is in 
the proper sense of the term a popular book for popular use. D. F. 0. 



Art. XXII. — Tlie Ambulance Surgeon, or Practical Observations on Gunshot 
Wou7ids. By P. L. Appia, M. D., Fellow of the Koyal Society of ^•aples, &c. 
Edited by T. W. Nuxx. Assistant Surgeon to the 'Middlesex Hospital, and 
A. M. Edwards, F. R. S. E., Lecturer on Surgery in the Edinburgh Medical 
School. Edinburgh, 1862. 12mo. pp. 266. 

This volume contains the translation, somewhat condensed, of a French work 
on gunshot wounds, written by Dr. Appia, together with some additions made 
by the British editors. 

Dr. Appia's work is evidently the production of an accomplished surgeon, of 
one who has studied the literature of his profession, and who has himself, had 
experience both in hospitals and on the field. It is divided into two parts, the 
first treating in separate chapters of the nature and varieties, the diagnosis, the 
prognosis and complications, and the treatment of gunshot wounds, and the 
second part considers gunshot wounds in the different parts of the body. The 



1862.] 



Mitchell, Circulation in the Snapping Turtle. 



201 



general outline of the treatise is, therefore, the same as that in the favourite 
work of Professor Longmore, to which, though as a whole it must be considered 
as inferior, this will be found decidedly superior on the subjects of prognosis 
and of complications. Of course the tone of the work is altogether different, 
and, from being less dogmatic, it is more agreeable. 

The chapter on the first dressing of fractures of the limhs contains, among 
much other excellent matter, the description of an apparatus for fractures, 
which appears to enable the wounded man to be transported with remarkable 
facility under the most disadvantageous circumstances. As it is stated thaf, 
after having been tried in the army of Italy, this apparatus was introduced into 
the military hospitals of Paris and Turin, and into the Spanish army, it is 
evidently worthy of being made known in this country. 

The great peculiarity of this apparatus consists in a number of small splints 
and vulcanized India-rubber air-cushions, that can be inflated at pleasure, all 
bound in strong canvass, so that the limb can be entirely surrounded. The 
apparatus varies in the size and number of the cushions ; in the simplest, in- 
tended especially for wounds of the knee, the leg, and the foot, there are four 
cushions, about twenty inches in length and six in breadth, with five narrow 
splints, with three straps to buckle the apparatus around the limb. For frac- 
tures of the thigh and for complicated wounds of the knee, there is along splint, 
of very ingenious construction, composed of several pieces, intended to admit 
of its extension, and yet form as firm support as if they were all one piece of 
wood. The comprehension of the description of this apparatus is aided in the 
text by a number of figures. Dr. Appia says experience has proved that by 
this apparatus the leg is entirely secured from any shocks from without. " One 
may even sit down upon it violently, when fixed and buckled up, without the leg 
experiencing anything beyond a slight increase of pressure. All shocks from 
without spread immediately, by the law of undulations, through all the cushions, 
and produce only a trifling direct effect." 

There is little to be said that is favourable of the manner in which the British 
editors have performed their task in this volume,, whether as translators or as 
original contributors. As an example of the one the following extract will be 
sufficient, and the mistake as to the signification of la rage will be found 
amusing: — 

" All that reminds us of similar conditions produced by hydrophobia. I have 
observed a young girl who sunk in a few days after a fright which placed her in 
a condition between tetanus and passion (rage). She swallowed with difficulty, 
and only when the drink was brought to her from behind, and in almost total 
darkness ; my arrival, or the sight of any one approaching her, set up tetanic 
spasms. The post-mortem offered no explanation. To these negative precau- 
tions will be added the employment of direct calmatives, especially full doses of 
opium; Larrey advises its being associated with camphor." (pp. 99-100.) 

The original contributions of the editors, which consist of a short article on 
Disinfectants, and a part — sixty pages in length — on Surgical Appliances, have 
been added, it is to be hoped, without much reflection. W. F. A. 



Art. XXIII. — Experiments and Observations uponthe Circulation in the Snap- 
ping Turtle, Chelonura Serpentina, toith especial Reference to the Pressure 
of the Blood in the Arteries and Veins. By S. Wier Mitchell, M. D., Lec- 
turer on Physiology. Philadelphia, 1862. 4to. pp. 14. 

In this interesting memoir are detailed the results of a series of experiments 
instituted with the view of determining in the snapping turtle the force of 
the heart's coatraction, the degree of the arterial and venous blood-pressures, 
and the influence exerted upon these by inspiration, expiration, and muscular 
exertion. 

The instrument used in these experiments was the haemometer of Magendie, 
as modified by Bernard, and described by him in his well-known lectures on 
the "Liquids of the Organisms." 



202 



Bibliographical Notices. 



[July 



From observations made upon the pressure of the blood in the carotid arteries 
of eight snapping turtles, Dr. Mitchell found that the minimum pressure in the 
artery is about one-third that in the artery of a mammal, or as 33.3 to 110, 103 
or 95, according to the animal chosen for comparison. 

" The force of the heart-act in the turtle elevates the column, on an average, 
11 m. ra., which is about the pressure observed in a dog of middle size when 
tranquil, and when the respirations do not prevent accurate observation of the 
influence of single pulsations, as is commonly the case. 

• " The impulse conveyed to the column of blood during the systole of the heart 
in the turtle is somewhat different from that of the mammal. In place of a 
sudden and abrupt motion, as seen in these latter animals, the mercury moves 
so slowly that the time of its rise during a systole may be estimated at one 
second, the period of fall being one second and one-fifth. The rise of the mer- 
cury was usually steady and regular ; its fall was broken and irregular, so that 
after falling two-thirds of the distance rapidly, an equal time was occupied in 
effecting the remaining third of the total descent. The number of heart-pulsa- 
tions varied in the eight animals examined from 25 to 40. In the individual 
cases its number was scarcely altered during the whole observation." 

The full and slow expiration which forms the first act of the respiratory pro- 
cess in the turtle exerts no marked effect upon the arterial pressure. The long 
inspiration which follows usually increases this pressure a little. The short 
expiration which terminates the respiratory series at once varies the arterial 
pressure. 

" The effect of muscular movement upon the pressure of the blood in the 
arteries was well marked and interesting. During violent movement the force 
of the heart remained unaltered, but the whole column of mercury rose, a result 
which attained to a maximum when the movements were coincident with the 
long inspiration and the short expiration which terminate each single series of 
respiratory movements. On such occasions the mercury sometimes rose as high 
as 70 m. m., and the action of the heart was irregular and unequal in force. 
Immediately after the movements were over, the mercurial column fell to a 
much lower point than usual, and then gradually ascended to the normal 
standard." 

We regard this monograph as an inte^:'esting addition to the literature of ex- 
perimental physiology, and we hope that the author will complete the study so 
well begun, by future more elaborate investigations. J. A. M. 



Art. XXI Y. — A Manual of Medical Diagnosis ; being an Analysis of the Signs 
and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant 
Physician to St. George's Hospital, &c. &c. Second American, from the 
second and revised London edition. Philadelphia : Blanchard & Lea, 1862. 
8vo. pp. 451. 

Having fully reviewed this work when it first appeared, a short time since, it 
is sufficient now to say that the rapidity with which the first edition has been 
exhausted shows the appreciation in which it is held by the profession. 

The very early period, the author states, at which a call has been made for a 
second edition of this manual has prevented his attempting anything in its revision 
beyond verbal alterations and minor additions. And he very modestly adds : 

While I take this opportunity of expressing my gratitude for the hearty good 
will with which my effort to supply an acknowledged deficiency has been received, 
and for the kindly tone of all the criticisms which have reached me, I cannot 
but feel that it owes its success more to the earnestness of purpose which cha- 
racterizes the students of the present day than to any merit of its own." 

We commend the work to the medical student as affording useful aid in ob- 
taining knowledge in a department of our science, the acquisition of which is 
essential, that our science may rest on a sure and solid foundation. 



1862.] 



203 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICxiL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Tactile Sensibility of the Hand. — Dr. Ballaed read before the 
Royal Medical and Cliirurgical Society (March 11) a paper, the first of a series, 
on the tactile sensibility of the surface of the body. The method he has em- 
ployed for ascertaining the sensibility of the parts examined was that known 
as Weber's ; but inasmuch as the results of this method vary according as the 
points of the compasses are laid in the direction of the long axis of a part or 
transversely to it, he employs the sum of the numbers obtained by an observa- 
tion in each direction as representing the true sensibility of any part. The 
numbers are given in English inches and decimals. He considers that the hand, 
being par excellence the organ of touch, and possessing on the whole the highest 
amount of sensibility, and giving thus readily a standard for comparison of sub- 
jective impressions made elsewhere, it is important that it should be the organ 
first examined. The paper is based upon the results of observations made upon 
142 points upon the surfaces and borders of the author's own hand and fingers 
— in all, therefore, of 284 separate observations. It consists mainly of elaborate 
tables, from which the author deduces in due order the general sensibility of the 
hand and its surfaces and borders, and separately of the metacarpal portion, 
fingers, and thumb. He not only compares these several parts between them- 
selves, but points out the relative sensibility of the lateral halves of the hand, 
these being related to the freer motion imparted to the radial half ; and of the 
centre to the sides, as showing at what parts of the hand the sensibility is highest 
at any given distance from the wrist. The following are some of the more im- 
portant deductions : The most sensitive spot of all he finds to be the tip of the 
index finger, in which he differs from Weber, but agrees with Yalentin. The 
sensibility of this spot is represented by the number .35 in. The spot where he 
found the lowest sensibility (.5.0 in.) was on the dorsum of the hand, opposite 
the base of the fifth metacarpal bone. The palmar surface of the hand was in 
all parts more sensitive than the dorsum ; but this was not the most sensitive 
part, for next to the tips of the fingers stood in order the two borders, the radial 
border being more sensitive than the ulnar. As pointed out by Weber, he also 
found that the sensibility of the hand increases from the base towards the ex- 
tremity ; but the author exhibits this fact by accurate numbers, and demonstrates 
not only the increase but also the rate of increase on each surface and border 
of the hand and of each finger separately. He finds the most rapid increase in 
sensibility to take place at the spot where the fingers actually commence, not 
where they apparently commence, and thus not at- the clefts, but opposite the 
metacarpo-phalangeal articulations, and again at the middle of the last phalanges 
on approaching the tips of the fingers. Perhaps the most interesting and im- 



204 Progress of the Medical Sciences. [July 

portant demonstration of all is that which relates to the fingers and their several 
surfaces. On the whole, the most sensitive finger is the index, and the sensitive- 
ness shades off towards the ulnar side of the hand ; and the most sensitive por- 
tion of the index, next to the tip, he finds to be its radial side. Of the little 
finger, the most sensitive part is the ulnar side, and he connects these two facts 
with those parts entering into the constitution of the borders of the hand at large. 
Of the palmar surfaces of the fingers, that of the index is the most sensitive ; 
of the dorsal surfaces that of the ring finger is the least sensitive. As respects 
the radial sides of the fingers, he finds the radial side of the index to be the 
most sensitive, and that the sensibility shades off as the fingers are farther re- 
moved from the radial side of the hand, till it becomes least upon the little 
finger. As respects the ulnar sides, he finds that that of the little finger is the 
most sensitive, and that the sensibility becomes less as the ulnar side of the hand 
is distanced ; with this remarkable exception, however, that the high sensibility 
of the index is provided for by its ulnar side standing next in rank to that of the 
little finger. Of the three intervals between the fingers, that whose approxi- 
mating surfaces possess the highest sensibility is the interval between the index 
and middle fingers. The thumb is, for the sake of convenience and simplicity, 
considered separately, and is regarded, from its carpal attachment onwards, as 
a finger not having a metacarpal element. It is thus compared in the paper 
with the fingers, from their metacarpo-phalangeal joints onwards. Appended 
to the paper are tables exhibiting the observed sensibility in each direction at 
the several spots examined, and four photographs on which are marked the sums 
of the observations at each spot. The author reserves the consideration of the 
differences of result according to the direction in which the compasses are placed 
for a future communication. — Med. Times and Gaz., March 29, 1862. 

2. Valves of the Veins of the Extremities. — M. Yerneutl made the following 
observation, at the Paris Anatomical Society, on the venous system of the 
extremities. While some of the arteries are accompanied by only a single vein, 
others have two venous satellites. The former are the encephalic, pulmonary, 
cardiac, uterine, and thyroid veins, and those of the portal system. These are 
all destitute of valves, while the veins of the limbs, which are always double in 
relation to the artery, are all possessed of valves. Is there here anything beyond 
a mere coincidence, any relation of cause and effect? Is not the existence of a 
double vein the consequence of the presence of the valves ! When we contem- 
plate the amount of pressure exerted upon the valves by the column of blood, 
we feel surprised that these folds are enabled to fulfil their office, and that their 
resistance is not oftener overcome by the obstacle which they have to surmount. 
But our surprise ceases when we consider that each of the segments of the vein, 
of the portions comprised between two valves, is provided with what may be 
termed a safety canal, that is, a vascular tube, which, arising a little above the 
lower valve, is directed at first horizontally, then vertically, and then again hori- 
zontally, so as to enter above the superior valve, presenting towards the superior 
extremity of its vertical portion a valve so disposed that the blood may in this 
safety canal flow towards the heart, but not in the contrary direction. Each 
segment of the vein is provided with a similar canal ; and supposing these canals 
conjoined, they would constitute a single safety-tube, the vertical portions of 
which represent the second vein attached like the first to the artery, while the 
horizontal portions represent a transverse anastomoses which establish a con- 
stant communication between the two parallel veins. This safety-tube is pro- 
vided with valves disposed as noted, and which only allow of a concentric move- 
ment of the liquid. The second vein thus serves as a derivative for the first, 
which in its turn plays a similar part for the second. From this reciprocity of 
action there necessarily results a well nigh complete equality of volume for the 
two vessels. " This explanation applies to all the veins of the extremities, and, 
in a general manner, to all veins having valves. The femoral vein, which at 
first sight seems to offer an exception to the rule, nevertheless presents the same 
disposition, for an attentive examination will demonstrate that there exists by 
its side a second vessel of smaller dimensions, communicating with the first by 
numerous anastomoses, each of which always opens into the principal vessel 



1862.] 



Anatomy and Physiology. 



205 



above a valve. — Med. Times and Gaz., May 10, 1862, from Balletin de la Soc. 
Anat., vol. xxxvi. 

3. Marriages of Consa,nguinify and Deaf -Dumbness. — M. Boudin, so well 
;]?nown for his researches in medical statistical questions, thus concludes an 
interesting inquiry concerning the effects of marriages of consanguinity : 1. 
The opinions hitherto delivered, whether for or against the hurtfulness of these 
marriages, have, for the most part, not been based upon conclusive proofs. 2. It 
is the statistical method that can alone supply a scientific solution of the pro- 
blem. 3. It results from my own researches that consanguineous marriages are 
contracted in France at the rate of 2 per cent. ; and that deaf-mutes are the 
issue of consanguineous marriages in the proportion of 28 per cent, at the Paris 
Imperial Institution, 2.5 per cent, at Lyons, and 30 per cent, at Bordeaux. 4. 
Marriages between nephews and aunts are contracted in France in the propor- 
tion of 0.014 per cent, (fourteen thousandths per cent.), while deaf-mutes are 
the results of such marriages in the proportion of 2.04 per cent. — in other words, 
deaf-mutes resulting from such marriages are 145 times more numerous than 
they should be. 5. Marriages between uncles and nieces are contracted in the 
proportion of 0.04 per cent, (four hundredths), and the deaf-mutes resulting from 
such marriages reach 1.61 per cent., i. e., the danger of engendering deaf-mutes 
is 40 times greater in this kind of alliance than it is in ordinary unions. 6. Mar- 
riages between cousins german are contracted in the proportion of 0.77 per 
cent., and deaf-mutes are produced in the proportion of 18.47 per cent., i. e. 
24 times more frequent than they should be. 7. The proportion of deaf-mutes 
proceeding from a consanguineous origin would be still greater if we could take 
into account those which proceed indirectly from consanguineous marriages. 
8, While at Berlin the proportion of deaf-mutes is but 6 in 10,000 among the 
Christians, it is 27 in 10,000 among the Jews. 9. In nearly the whole of the 
cases, the deaf-mutes issuing from consanguineous marriages have parents who 
are perfectly healthy and exempt from hereditary affections. 10. When male 
and female deaf-mutes intermarry, not being consanguineous, the children they 
produce, with rare exceptions, are exempt from dumbness and deafness. 11. In 
the face of such facts as these, the hypothesis of a morbid hereditariness, em- 
ployed for the explanation of the frequency of deaf-dumbness among infants 
the results of consanguineous marriages, is radically false. 12. The hypothesis 
of the pretended harmlessness of consanguineous marriages is contradicted by 
the most evident and well-verified facts, and can only be excused by the diffi- 
culty, or rather the impossibility, of giving a physiological explanation of the 
production of infirm children by parents who are physically irreproachable. 
M. Boudin, in proof of the practical importance of this kind of inquiries, states 
that since 1831 more than 15,000 men have been exempted in France from mili- 
tary service on account of deaf-dumbness, dumbness, or deafness. — 3fed. Times 
and Gaz., May 10, 1862, from Receuil de M^m. de Med. Militaire, March. 

4. Marriages of Consanguinity and their Influence on Offspring. — A very 
interesting and elaborate paper on this subject has been lately read (February 
6, 1862) before the Medico-Chirurgical Society of Edinburgh, by Dr. Mitchell, 
of which the following is an abstract : — 

Dr. Mitchell began by a brief account of existing opinions on this subject. He 
pointed out that whatever the practice may be, such alliances are, and have 
always been, almost universally condemned both by the general public and the 
medical profession. And as every one has considerable opportunities of testing 
its accuracy by personal observation, he argued that the probability of its being 
a traditional error becomes very small. He stated that the literature of this 
subject abounded in simple assertion, which might be correct, but that the basis 
on which important conclusions are made to rest is often not given at all, and 
when given, is undefined or clearly too narrow. He pointed out that much of 
the general and professional opinion on this subject hangs on a peculiar kind of 
evidence. A¥e are presented with the question, "Do these marriages injure the 
offspring?" and we search for instances from the history of which the answer is 
to be given. Now it is certain that all those cases which have been marked by 



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[July 



misfortune will first rise up, while many of those which have exhibited no evil 
effect or no peculiarity will probably be passed over because forgotten. Facts 
so collected lead to inferences beyond the truth — an exaggeration of a calamity 
whose proper dimensions are sufficiently great. Without intention they are 
selected cases. Being true in themselves, they show what is possible, but they 
by no means embody the rule. He then detailed the results of 45 cases so col- 
lected by himself. Some of these he discussed individually as illustrative of 
atavism, of the connection between heredity and his subject, of the various forms 
of injury and modes of manifestation, etc. The line of investigation to which 
these considerations had led was then described. Instead of grouping cases, 
supplied by his own memory or the memory of others, he took small communi- 
ties, examined the history of every such alliance in these communities, as well 
as of every marriage without kinship, and compared these. And in order further 
to test the result of such inquiries, he ascertained, with as much accuracy and 
precision as possible, the history of the parentage of all insane or idiotic persons 
in a particular district of the country. These inquiries were conducted by himself, 
bis official duties giving him the necessary opportunities. In addition to show- 
ing the influence of consanguinity of parentage on the production of the actual 
idiocy of the country, he also showed its power as a cause of actual deaf-mutism. 
And he examined at some length the argument from in-and-in breeding in the 
lower animals. By this mode of investigation he hoped to obtain sounder con- 
clusions as to the character and measure of the pernicious influence which blood 
alliances exercise on the offspring. 

Taking the whole number of idiots examined (711), out of every eight one was 
the fruit of a union of consanguinity. This includes those cases where the rela- 
tionship of the parents could not be ascertained, as well as illegitimates. When 
these were excluded, and when those idiots horn in marriage of parents related 
by blood were compared with those horn in marriage of parents not so related, 
they stood in the proportion of 1 to 5.8 — or more than every sixth idiot born in 
wedlock was found to be the child of cousins. It further appeared that the 
influence of kinship of parentage as a cause of idiocy manifested itself still more 
strongly when those cases only were dealt with in which more than one idiot had 
occurred in a family. 

As regards the deaf-mute the influence was not so marked, but was still very 
evident. In Great Britain one deaf-mute in 16.7 was found to be the child of 
cousins. This closely agrees with Mr. Wilde's estimate for Ireland, but is not 
so high as that formed by Dr. Peat and Mr. Buxton. 

These subjects, which were discussed at considerable length, are here stated 
in the briefest manner possible ; but when the paper is published the whole 
details will be laid before the profession. 

Dr. Mitchell, in examining the argument from in-and-in breeding in the lower 
animals, discussed the views on this subject expressed by well-known writers and 
stock-breeders, and concluded with the following remarks : — 

" Everything is secondary to the property of producing in the shortest time 
the largest quantity of flesh with the least consumption of food. The great 
desideratum is an early arrival at maturity, or premature age — an early maturity, 
too, of particular parts, of muscle and fat especially. 

After all, then, in these cases where in-and-in breeding has been practised 
with so-called good results, the issue is nothing but the development of a sale- 
able defect, which, from the animal's point of view, must be regarded as wholly 
unnatural and artificial, and not calculated to promote its well-being, enjoy- 
ment, or natural usefulness. And in this view all the seeming contradictions 
to the law disappear. By in-and-in breeding we may establish an artificial type, 
and fix a peculiarity which is unnatural, if not morbid, and whose only value is 
its profitable convertibility into gold, but no evidence whatever exists in these 
apparent anomalies that by such a system of breeding we can improve the natural 
animal. 

"Strictly viewed, Collin's ' Comef was nothing more or less than a perfect 
pathological specimen — a deviation from a natural animal — perfect in a desired 
direction. Yet, pro tanto, the animal was the less useful to himself, had he been 



1862.] 



Anatomy and Physiology. 



207 



left to himself, and had he been deprived of the artificial keeping and manage- 
ment which his artificial condition demanded. 

" When it became desirable to perpetuate a peculiar malformation in man, 
then in-and-in breeding may have good results — the results being estimated as 
good or bad according as they realize the end in view. I know the case of a 
man who has supernumerary little fingers, and whose two children and seven 
grandchildren have the same. Were additional little fingers of great value, the 
true way to obtain a race having this peculiarity, would certainly be to establish 
blood alliances in this family ; and when we obtained the desired excess of fin- 
gers in the offspring, we should then have as good reason to say that kinship of 
parentage had done good and not harm (since we should have in the way we 
wanted a more perfect animal); — as the farmer has to say, it has done no harm 
but good, when he looks on his Leicester sheep, with little heads and small bones 
— their lymphatic temperaments enabling them to feed without disturbance — 
fat, ripe, and ready for sale in their very lambhood. 

"Till the excellences of man are estimated by weight; till the man be an arti- 
ficial, and not a natural man ; till we want legs at the expense of arms, or arms 
at the expense of legs, or head at the expense of body, or body at the expense 
of head ; till we want maturity in babyhood and premature age ; till the perfect 
man be something else than a well-balanced development of all his components, 
bodily and mental, we must apply the experience of breeders of artificial stock 
cautiously and with reservation in human physiology." 

That part of the communication which related to the examination of particular 
communities embraced several fishing villages on the N. E. and S. E. coast of 
Scotland, as well as iSt. Kilda, Bernera, and other islands off" the N. W. coast. 
The account of this investigation was full and minute, and the aspects of the 
question thus brought under notice were very varied. The nature of some of 
these will be gathered from the conclusions to which Dr. Mitchell has been led, 
and which are stated below. Many apparent exceptions were pointed out, and 
attention was directed to those things by which the effects are influenced or 
modified. The general teaching of the whole, however, decidedly pointed to 
injury to the offspring as the result of a blood-relationship jDetween the parents. 
It is not possible to give here even an abstract of this portion of Dr. Mitchell's 
paper. Each place selected for investigation differed widely from the others, 
and by peculiarities so decidedly aftecting the results, that nothing short of a 
full detail would be satisfactory. The extraordinary influence of trismus on the 
infant population of St. Kilda, for instance, appeared to destroy the lesson which 
it was expected to teach. One pleasing conclusion to which these investigations, 
led was, that such marriages are not so frequent in Scotland as has been long 
supposed ; and it was stated that the enlightened proprietor of the Lewis does 
all he can to prevent their occurrence among his tenantry. 

Dr. Mitchell's conclusions were of two kinds — those resting on a basis of 
stated facts, and those arrived at insensibly and irresistibly by himself during 
the progress of inquiry, and founded on observations which it would be difficult 
if not impossible to tabulate, or even state with precision. These inferences 
may be thus briefly given, but each in its enunciation was considerably amplified 
by the author. 

I. That it is a law of nature that the offspring is injured by consanguinity in 
the parentage. 

II. That this injury assumes various forms. 

III. That in all classes and conditions of society its manifestations are not 
alike. 

lY. That the evil appears to be in some measure under control. 

Y. That isolated cases or groups of cases may present themselves where, in 
addition to consanguinity, all the other circumstances are so unfavourable that 
a confident prediction of much evil would be justified, yet where no such evil 
appears. 

YI. That, where the children seem to escape, the injury may show itself in 
the grandchildren ; so that the defect may be potential when it is not actual. 

Yll. That, as regards mental disease, unions between blood relations influence 
idiocy and imbecility more than they do the other forms of insanity. 



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V^III. That, with reference to Scotland, it may with safety be estimated that 
about 9 or 10 per cent, of existing- idiocy is referable directly to consanguine 
marriages. In forming this estimate the proper deductions were liberally made, 
so as to avoid an over-statement. 

Dr. Mitchell concluded by an attempt to explain the manner in which these 
sad effects result from such unions. Transmissible peculiarities of all kinds are 
apt to be thus intensified. If there are diseases in the parents, there are aggra- 
vated diseases in the offspring ; but though the diseases may not be manifest in 
the parents, they may be so increased as to constitute evident disease in the 
children.— Med. Journ., March, 1862. 



MATERIA MEDICA AND PHARMACY. 

5. Action of Alcohol as an Aliment in Disease. — Dr. F. E. Anstie, Assist- 
ant Physician to the Westminster Hospital, relates [London Medical Review, 
April, 1862) four cases, one of pericarditis, two of pneumonia, and one of pleu- 
risy, illustrative of the action of alcohol as an aliment in disease. ' These cases, 
he states, "are by no means the only ones which I could quote from my own 
practice, which might serve to throw light on the question whether alcohol does 
or does not act as a food. I have selected them, because they are the only cases 
of which I possess notes in which a crucial experiment was performed, viz., the 
administration of no food (for none other could be retained on the stomach) but 
alcohol, in the shape of wine or spirit, mixed with a little water. I think my 
readers must allow that there is no imperfection in the conditions of the experi- 
ments which is at all important ; and if this be so, the evidence which they 
afford is very important. It may be briefly summed up thus : — 

"1. Alcohol is capable of sustaining life, in the absence all other foods, for 
many days. 

" 2. During acute 'diseases, alcohol is sufficient, without the help of any other 
food, to prevent emaciation of the body, and also the extreme lowering of mus- 
cular strength, which would render the period of convalescence tedious. 

"3. Given in acute disease no amount of alcohol which the exigencies of the 
case require will cause inebriation ; on the contrary, delirium, unless it depend 
on inflammation of the brain, may be always checked by the administration of 
alcohol. 

"4. That the demand of the system for alcohol in acute disease is in inverse 
ratio to the power of assimilating other foods. 

"To these conclusions I may add some others, to which I am led, not by the 
above cases only, but by a very large number of others also. 

"1. It is not true that alcohol may only be given with advantage, in acute 
disease, when the skin is already moist and perspiring. On the contrary, nothing 
has been more common in my experience than to see patients whose skin had 
previously been dry and burning hot, break out into a refreshing sweat after 
some hours of steady perseverance in the administration of alcohol in two 
drachm doses every half hour. 

"2. It is not true that the treatment of acute disease by large doses of alcohol 
involves any danger whatever of laying the foundation of habits of drunkenness. 
If the alcohol has been judiciously administered, in sufficient quantities, and yet 
not too large, the moment that the appetite for ordinary food returns the desire 
for the temporary substitute will cease. I fully agree with the important remarks 
recently made on this subject by Dr. Druitt. It may be laid down as a rule 
that, both in disease and in health, the taking of so large a quantity of alcohol 
as, under the circumstances, is sufficient to produce intoxication, tends to pro- 
duce a craving for the stimulus ; and it is equally certain that the timid' and 
inadequate use of stimulants in acute diseases tends to produce a similar bulimia. 
But the taking of even a bottle or two bottles of brandy a day, when the case 
requires it, does not engender the smallest taste for alcohol after the return of 



1862.] 



Materia Medica and Pharmacy. 



209 



health. And the daily use, during health, of a quantity of alcohol which is in- 
sufficient to produce any, even the earliest, symptoms of inebriation, does not 
occasion the smallest craving for an increase of the dose." 

6. Therapeutic Properties of the Peroxide of Hydrogen. — In our number for 
January, 1861, p. 249, we noticed the interesting researches of Dr. Richardsox 
relative to the therapeutic properties of the peroxide of hydrogen. Since then 
Dr. Richardson has been pursuing his investigations, and in a paper recently 
communicated to the Medical Society of London, he has given the results at 
which he has arrived. 

After repeated and long-continued experiments in reference to the different 
processes for making the solution of the peroxide of hydrogen, Dr. R. has ulti- 
mately come to the conclusion that no plan is so good as the one invented by 
Thenard, in which the peroxide of barium is used as the agent for supplying the 
oxygen, with hydrochloric acid as the displacing body. The strength of the 
solution was next discussed, and it was shown that a solution charged with ten 
volumes of oxygen was the best and most applicable. The dose of this solution 
for an adult was from one drachm to half an ounce in a liberal quantity of water. 
The compatibility of the peroxide solution with other medicines was next con- 
sidered, and it was intimated that, as a general rule, the solution should be given 
separately, or, if mixed with another remedy, should be so admixed at the period 
of administration. 

From the narration of these particulars Dr. Richardson passed in review the 
results of his experience in disease. He had used the remedy now in 223 in- 
stances, viz., in simple diabetes, 3 ; in diabetes complicated with phthisis, 2 ; 
in chronic rheumatism, 1 : in subacute rheumatism, the continuation of an acute 
attack, 2 ; in mitral disease with great pulmonary congestion, 4; in irregularity 
of the heart, with cardiac apnoea, 3 ; in struma, with enlargement of the cervical 
glands, 2 ; in struma, with formation of purulent matter constantly recurring, 
1 ; in mesenteric disease, 1 ; in simple jaundice, 1 ; in jaundice complicated with 
cardiac and hepatic disease and ascites, 1 ; in cancer affecting the glands of the 
neck, 1 ; in pertussis, 9 ; in chronic bronchitis, 9 ; in bronchitis complicated 
with mesenteric disease, 1 ; in chronic laryngitis, 3 ; in anaemia, 44 ; in phthisis, 
first stage, 66 ; phthisis, in the second stage, 31 ; phthisis, in the third stage, 
13 ; in phthisis, first stage, complicated with bronchial disease, 6 ; in phthisis, 
second stage, with bronchial disease, 3 ; phthisis, with valvular disease of the 
heart, 2 ; and also in a few cases of dyspepsia. 

Analyzing these cases, the author came to the following conclusions : That in 
the treatment of diabetes, the peroxide, while it reduced the specific gravity of 
the renal secretion, increased the quantity ; so that its value in this disease was 
inappreciable. In chronic and subacute rheumatism it was of great value. In 
valvular disease of the heart, attended with pulmonary congestion, it largely 
relieved the attendant apnoea. In struma it removed glandular swelling, like 
iodine. In mesenteric disease it improved the digestion, and favoured the tole- 
rance of cod-liver oil and iron. In jaundice it exercised an excellent efiect, by 
improving the digestion and causing a free secretion. In cancer it seemed to 
exert no influence. In pertussis its value was very remarkable ; it cut short the 
paroxysms, and removed the disorder altogether, quicker than any other remedy, 
except change of air. In old-standing bronchitis, during attacks of suffocative 
dyspnoea, it afforded rapid relief In chronic laryngitis, its caustic character 
rendered its administration painful. In anaemia, while it exerted no specific 
influence per se, yet combined with iron it increased the activity of that drug. 
In phthisis pulmonalis, in the first stages, it greatly improved digestion and 
increased the activity of iron ; while in the last stages it afforded unquestionable 
and wonderful relief to the breathlessness and oppression — acting, in fact, like 
an opiate, without narcotism. 

After describing the use of the peroxide in dyspnoea and epilepsy, the author 
dwelt finally on the anomalous symptoms excited by the solution ; pointing out 
the singular fact that in some instances where it had been pushed freely it had 
produced profuse salivation. That chlorine and iodine had in these effects an 
No. LXXXYIL— July 1862. 14 



210 



Progress of the Medical Sciences. 



[July 



analogy to salts of mercury was a fact long recognized; but that oxygen in the 
active state exerted the same physiological action was a fact as remarkable as 
it was interesting. It opened an entirely new field of inquiry. It suggested the 
possibility that the salts of mercury did not act by virtue of the mercury as 
mercury at all, but by the agency of the oxygen, chlorine, or iodine which they 
conveyed into the organism. It suggested also the propriety of ascertaining 
whether chlorine or peroxide of hydrogen might not replace mercury in cases 
where it was supposed to be a specific. If this suggestion were carried out and 
an affirmative were supplied, the method of cure in the disorders specified would 
be rendered much more simple and rational. — Lancet, April 12, 1862. 

7. Podopliyllin. — Dr. Gardner states {Lancet, March 15, 1862), that "from 
1856 to the present I have constantly employed podophyllin in my practice, and 
the result of my experience is as follows : — 

" 1. I know no other substance which so certainly produces bilious evacua- 
tions when the liver is full of bile ; I do not even except calomel ; a full dose — 
namely, two grains (when pure) — producing effects very similar to those result- 
ing from ten grains of calomel. I have seen jaundice, where the stools exhibited 
no trace of bile and the skin and eyes were of a deep yellow, cured by a single 
dose, incredible quantities of bile being evacuated. With respect to this action 
of podophyllin, I think I am warranted in asserting, strange as it may appear, 
that if, after a free evacuation of bile, a second dose of two grains is given within 
two or three days, it produces no effect whatever, not even purging. This cer- 
tainly happens in ordinary engorgement of the liver, if not in jaundice. The 
purgative eftect in nearly all cases is not direct — that is, it does not act on the 
bowels for ten or twelve, or even in some cases sixteen or twenty hours ; the 
purging appears to result from the large amount of bile thrown into the bowels. 
Sometimes its action is without uneasiness, but generally there is a sense of tor- 
mina or twisting and spasmodic action in the upper region of the abdomen and 
about the navel. 

" 2. In the torpid liver of persons who have resided in tropical climates, a 
dose of one grain seldom if ever fails to rouse the secretory action of the organ 
and bring bilious coloured stools ; but it often requires twenty-four to thirty-six 
hours to act on these patients. It is only at long intervals that the dose requires 
to be repeated. These patients are, as is well known, accustomed to take blue- 
pill, and often suffer much from nervous irritability, ulcerations of the mouth, 
diarrhoea or costiveness, or both alternately, depression of spirits, and many other 
evils, which all pass away after a dose of podophyllin. 

" 3. In the constipation which often besets patients in phthisis — as, I think, 
most frequently from fatty liver — the podophyllin is the best aperient I have 
found, though, for the above reasons, very long in acting on the bowels. I have 
given it in all stages of this disease with marked benefit, not obtainable from 
any other purgative. 

"4. I have given it much in gout, deeming it an important point of treatment 
to secure free biliary evacuations, which it invariably does ; but I have not 
trusted to it alone, as I think might be safely done; and the same in acute rheu- 
matism. My mode of giving podophyllin has been to make it into a small pill 
with soft extract of henbane, or one-eighth of a grain of extract of belladonna, 
or more frequently with another concentrated vegetable resinoid — to be described 
in a future paper — leptandin, either of which moderates the tendency to harsh- 
ness of the podophyllin. 

5. In constipation without other disorder, I usually give one-sixth to one- 
fourth of a grain in a pill of compound rhubarb-pill. It acts thus very much the 
same as we expect a grain of calomel or five grains of blue-pill with the com- 
pound rhubarb-pill to act ; and I consider that it may in very numerous cases 
be substituted for mercurials with great advantage. 

" 6. Whenever I have deemed it desirable to evacuate or stimulate the liver, 
as in bronchitis, fevers, headaches, &c., I have used this medicine with highly 
satisfactory results. 

" 7. Aware of the eulogiums which have been bestowed on podophyllin as an 
alterative, anti-syphilitic, &c., I cannot either contradict or confirm them from 



1862.] 



Materia Medica and Pharmacy. 



211 



my own observations ; but I have met with two or three cases where it unequivo- 
cally produced ptyalism. 

" Lastly. On my recommendation it has been introduced to the Jewish Hos- 
pital at Jerusalem, where liver disorders abound, and I have the general report 
that it is found to justify the most sanguine expectations of its remedial value ; 
and I may add, from many of my friends who have employed podophyllin, I have 
received opinions confirmatory of my views." 

We have been also favoured with the following : — 

" Dr. Waed has administered podophyllin during the past year at the Seamen's 
Hospital, Dreadnought, and in private practice in a considerable number of 
cases. The affections in which he has found it useful are cardiac, renal, and 
hepatic dropsies, an asthenic form of dropsy frequent amongst sailors, and not 
associated with organic disease ; congested and indolent liver. He has given it 
in doses of half a grain or a grain. Its action has been slow, ten or twelve hours 
having usually elapsed before it has eflfected evacuation of the bowels. In the 
majority of cases it has not occasioned discomfort in the way of nausea, griping, 
or depression. It is less hydragogue than elaterium, but never fails in its chola- 
gogue action ; producing copious bilious stools, semi-solid at first, subsequently 
watery. In two other cases, Dr. Ward has found it to linger for a considerable 
period in the bowels, and cause much griping and irritation ; but these results 
might be obviated by quickening its action by combination with some other 
drug. Dr. Ansel! informs Dr. Ward that he has given podophyllin in doses of 
a quarter of a grain twice a day in cases of amenorrhcea with constipation, 
and has found it act as a powerful cholagogue cathartic and emmenagogue. 
The drug may certainly be regarded as a valuable addition to our materia 
medica." 

Dr. Ramskill, Physician to the London and Epileptic Hospitals, has favoured 
us with the following valuable remarks and cases. It will be observed that his 
experience of the effects of podophyllin is remarkably confirmatory of the opin- 
ions of the American physicians : — 

" Podophyllin may be given alone, but it is apt to gripe. At the London 
Hospital I invariably order a pill of equal parts of podophyllin and extract of 
Indian hemp. It is then slower of action than when given with hyoscyamus or 
conium, but less frequently gripes. At the Epileptic Hospital I have not for 
more than a year used any other pill as a purgative for epileptic patients, except 
under special circumstances. The formula I use is extract of belladonna and 
podophyllin, of each one-fourth of a grain, made into a pill with extract of mines- 
permium fenestratum.^ The latter drug is rich in berberine. and is used as a 
tonic adjuvant. Belladonna has itself a laxative tendency; but it is not used 
for that property. One or two such pills are usually sufficient, if continued for 
two or more successive nights. 

"The cholagogue action of podophyllin is not confined merely to the period 
of its administration ; large quantities of bile will continue to flow for several 
days after ceasing its employment. 

"Latterly, at the London Hospital, I have administered podophyllin in about 
fifty cases a week. In three cases only has its action been seriously complained 
of, the complaint being its excessive action, with pain. The dose was, in fact, 
too large — namely, half a grain, all the three patients being women. Except 
under such circumstances, the evacuations from podophyllin are rarely watery ; 
they are always fecal at first, followed by the peasoup-like evacuations we see 
follow from the continued use of colchicum, but of a brighter colour. With 
•regard to the colour of feces generally, I must say that a brown colour does 
not, in my opinion, prove the presence of bile, for the dark epithelium thrown 
oflFin the colon may cause this ; neither does a pale clayey series prove that the 
liver does not secrete bile, for this may be limited in quantity and absorbed for 
well known uses in the economy. (Liebig.) But a quart or more of a golden- 
yellow fluid, yielding the usual reactions to bile-tests, will often follow the use, 
and demonstrate the cholagogue power, of the drug. 

"Podophyllin seems to me to rank near scammony as a purgative, but it 



' We shall give au account of this plant in a future paper. 



212 



Progress of the Medical Sciences. 



[July 



is milder in its action. As a cholagogue it stands pre-eminent and alone — far 
before mercury or any other drug that I have ever administered. I am almost 
tempted to say, that there is no real cholagogue known in medicine except podo- 
phyllin. Will calomel or blue-pill procure in any case an unequivocal discharge 
of bile apart from its purgative or laxative action — i. e., apart from its deriva- 
tive influence, accompanied by increased secretion of the small and large intes- 
tines ? Is not this the mode in which the biliary secretion is liberated by these 
mercurials? Podophyllin, on the contrary, in very small doses, will procure an 
abundant flow of bile, and often induce its discharge by vomiting, before, or even 
sometimes without, any purging. My idea respecting the modufi operandi of 
mercurials is supported by very good authority — [vide Morehead, On the Dis- 
eases of India)." 

8. Therapeutical Properties of Malt. — M. Fremy has made use of malt as a 
remedial agent. That prepared by Nitsohke, a brewer near Berlin, he has found 
to be of superior quality to that obtainable at Paris ; it is more soluble, aroma- 
tic, and agreeable. The malt-powder may be given internally in the form of 
decoction, and applied externally by means of baths. The substance was tried 
on sixty-four subjects of well-marked phthisis ; but the results were trifling, 
beyond a certain degree of temporary amelioration. It was, however, of greater 
service in cases of chronic bronchitis, early phthisis, and chronic pulmonary 
catarrh — its utility being very marked in this last affection. In simple dyspep- 
sia it is of use when the saburral condition of the tongue has been removed. In 
Germany it has been found to be of great advantage in the chloro-anaemia of 
nurses. " The powder is a true analeptic, and the bitter principle, which it 
owes to the presence of lupulin, renders it very efficacious in re-establishing the 
functions of the stomach in dyspepsia." — 3Ied. Times and Gaz., March 15, 1862, 
from Journ. de Chimie Med., Feb. 

9. Substitution of Daturia for Atropia. — For some time past M. Jobert 
has substituted for the preparations of belladonna a solution of daturia as a 
mydriatic. He finds it is three times more powerful than atropia, and can 
therefore be employed in proportionally less quantities. It does not produce 
pain when introduced into the eye, nor does it confuse vision like belladonna, 
while its effects are more constant and its action more persistent. — Bull, de 
Therap. 

10. Antiseptic Properties of Ammonia. — Dr. Richardson, in a paper read 
before the Medical Society of London, states that his earliest researches were 
directed to the study of the antiseptic properties of gases, and recalled attention 
to the communication he had made to the Society on this subject in 1850. His 
present inquiry and application of ammonia as an antiseptic commenced in 1858. 
His attention was then directed to the fact, that the presence of ammonia effec- 
tually arrested the oxidation of various bodies, and even prevented the action 
of ozone. Believing that by an extension of the same law animal substances 
exposed to ammonia could be prevented from putrefaction, he kept blood and 
portions of tissues in contact with simple ammoniacal vapour, and with results 
which were most remarkable. Blood in an ordinary stopped bottle, if charged 
with ammonia so as to give a faint ammoniacal odour, would retain its freshness 
and many of its properties for years. Animal structures in like manner placed 
even so as to be massed together in bottles containing ammonia vapour, would^ 
retain their freshness for an unlimited time. Dr. Richardson now showed the* 
following specimens : The lungs of a calf which he had used for lecture purposes 
for six months, and which had been simply placed under a bell-jar, a little 
ammonia in solution being put over them from time to time ; a pancreas which 
had been kept for eighteen months in a bottle containing twenty minims of 
ammonia solution ; a kidney showing deep congestion, which had been removed 
sixteen weeks ; a bottle of mixed specimens, including portions of intestine with 
enlarged glands ; a bladder, the inner surface of which was injected ; a uterus 
and ovaries and a pancreas, all of which had been preserved lying close in one 
bottle for sixteen weeks ; also a portion of liver, which had been removed nearly 



1862.] 



Materia Medica and Pharmacy. 



213 



three years ; and a cancerous breast, which had been removed by Mr. Spencer 
Wells eight weeks before. The specimens all retain their freshness, and ad- 
mitted of dissection and examination as in the recent state. The author then 
described the method of applying ammonia. It was necessary, in the first place, 
to trust to the ammonia alone : specimens that were exposed first to spirit and 
then to ammonia vapour were always spoiled. For the preservation of fluids, 
such as blood or milk, it was merely necessary to add the alkali in solution in 
proportion, say of twenty minims, of the strong solution to two ounces of the 
fluid to be preserved. For tissues the plan was to place the specimen to be 
preserved in a stoppered bottle or under a bell jar, such as is used for wax 
flowers and ornaments, to place in the jar with the specimen a layer of felt or 
lint, charged with from ten minims to a drachm of the liquor ammonia fortis, 
and then to close the vessel or jar secure from the external air. For a luting 
in such cases soap answered best, or a mixture of soap and red lead. After this 
description, Dr. Richardson pointed out the practical value of the method. 1st. 
In conducting post-mortem inquiries it did away with all occasion for hurry. It 
was now only necessary at an autopsy to be provided with one or more jars, 
each containing say a drachm of liquid ammonia. The jars might now be filled 
with specimens, and if the stoppers were put in with care the specimens would 
retain their freshness for weeks, and even their microscopical characters. The 
only peculiar change was, that if much fat were present, the alkali formed with 
it a kind of soap ; a fact which explained the formation of adipocire in the dead 
subject undergoing slow decomposition. For forensic purposes this method of 
preserving animal structure was perfect, inasmuch as it added no mineral or 
poisonous matter, and yet secured the part to be examined free from change 
and from all offensive odour. Not only so, but important pathological changes, 
such as ulceration of intestine, could be kept under observation and submitted 
to any number of pathologists. He (Dr. Richardson) had found the system a 
very useful one, too, for lecture purposes, as it enabled him to show to his class 
real specimens of disease, such, for instance, as the scirrhous breast now going 
round, instead of casts or specimens softened, discoloured, and, indeed destroyed 
altogether by immersion in spirit. The last point to which Dr. Richardson 
drew attention had reference to the cause of the antiseptic power of ammonia. 
Ammonia being a product of decomposition had been looked on commonly as a 
substance provoking decomposition. But ammonia was truly the most powerful 
antiseptic known : it acted catalytically by preventing the union of oxygen with 
oxidizable bodies. An experiment was here performed illustrating this : half a 
grain of ammonia diffused through 40 cubic inches of air was shown to possess 
the power of entirely suspending the combination of oxygen with potassium on 
a surface of paper saturated with iodide of potassium, starch, and solution of 
oxygen, so long as the paper was presented to the ammoniated air ; but so soon 
as the paper was removed, the evidence of the combination, indicated by the 
■formation of the blue iodide of starch, was presented. In preserving animal 
structures in ammonia, the same experiment was virtually carried out ; the 
presence of the ammonia suspended the oxidation. There were other agents 
which effected the purpose, such as chloroform ; but the fact that these agents 
were indifferently soluble in water rendered them much less effective as com- 
pared with ammonia, which combined readily with the water contained in the 
tissues, and so perfected the preservation to the minutest point. In conclusion, 
the results presented tended to throw a light on the influence of the ammonias 
as the producing causes of some diseases, and as the curative remedies in other 
diseases. The same rule that pertained to dead pertained to living organic 
matter. Hence long exposure to ammoniacal vapour, by arresting oxidation, 
produced extreme anaemia and a low depraved condition of the system, alto- 
gether with reduced respiration, reduced appetite, reduced muscular power, and 
reduced energy. On the other hand, in cases where a rapid oxidation of the 
body was being determined attended with increase of heat and rapid disintegra- 
tion of tissue, the administration of ammonia, by arresting these changes, be- 
came in judicious hands the most powerful and effective of remedies. It checked 
decomposition by its action on oxygen ; it held the blood fluid by its solvent 



214 



Progress of the Medical Sciences. 



[July 



power as an alkali, and being volatile it inflicted no immediate injuries on the 
structures of the body. — Med. Times and Gazette, May 10, 1862. 

11. Inhalation of Pulverized Fluids. — M. Poggiale recently read to the 
Academy of Medicine an extremely elaborate report on the much disputed ques- 
tions connected with the inhalation of pulverized fluids. The various papers on 
the subject were so conflicting, their contradictions were so glaring, that it 
became an imperative duty for the Academy to ascertain with precision the 
amount of practical utility of this new method of therapeutic ministration. M, 
Poggiale began by establishing the fact that the authors who have inquired into 
the subject cannot agree as to the penetration of the pulverized fluids into the 
respiratory passages, and are at utter variance with each other, with regard to 
the refrigeration of the liquids operated on, the waste of the mineralizing ingre- 
dients of pulverized sulphurous water, and the medicinal effects of M. Sales- 
Girons' method ; he then carefully examined in succession all the elements of 
these intricate problems, and concluded as follows : — 

The experiments on animals and on the human subject, instituted by MM. 
Moura-Bourouillou, Tavernier, and Demarquay, the researches of M. Fournie, 
On the Introduction of Pulverized Substances into the Air-passages," demon- 
strate, beyond contradiction, that liquids reduced to spray actually penetrate 
into the respiratory ducts. 

On leaving the apparatus, pulverized fluids undoubtedly undergo some degree 
of refrigeration ; but, in a letter to the academy, M. Tempier states that this 
unfavourable circumstance may be neutralized by causing the spray to be emit- 
ted in an atmosphere saturated with steam, at a temperature higher than that 
of the pulverized water. 

With regard to the chemical changes induced by the method in sulphurous 
waters, M, Poggiale, while admitting their existence as a general fact, asserts 
that they are not the same for all waters of this kind. Thus, the waters of 
Enghien, which contain free hydrosulphuric acid, lose on an averege 60 per cent, 
of that ingredient. The waters of the Pyrenees, on the contrary, in which sul- 
phuret of sodium is to be found, are very slightly modified in the process in 
question. It would also appear that the waste of the sulphurous element is less 
considerable with M. Sales-Girons' apparatus than with M. Mathieu's instru- 
ment. 

The desulphuration is, in all cases, greater in proportion as the procedure is 
carried on at a more considerable distance from the spa, and the changes are, 
therefore, more obvious in the inhalation-rooms than when portable instruments 
are used. 

Another highly important question requires an answer. Is it possible, with 
the data in our possession, to describe with precision the therapeutic effects of 
the inhalation of pulverized fluids ? To this query the commission experienced 
much difficulty in framing a reply; thus, on the one hand, MM. Sales-Girons, 
Auphan, and Demarquay, assert that they have derived much benefit from the 
inhalation in chronic affections of the respiratory organs, and on the other hand 
Professor Champouillon and MM. de Pi6tra-Santa, Brian, Delore, and Fournie, 
utterly deny the efficacy of the method. M. Poggiale confined himself, there- 
fore, with undisguised regret, to an appeal to further inquiry, and moved that 
the thanks of the Academy be forwarded to the experimentalists above named, 
who have spared no efforts to dispel the clouds which obscure the question. — 
Journ. Pract. Med. and Surgery, also Gazette Hehdom., 10 Jan. 1852. 

12. Administration of Cod-Liver and other Oils. — Dr. Alexander Wallace, 
Physician to the Metropolitan Free Hospital, has instituted a number of experi- 
ments with a view of determining the best formula for the administration of 
oleaginous substances. Starting with the proposition that the digestibility of 
these substances depends, 1st, on their dilution ; and 2d, on their minute sub- 
division in a convenient menstruum, he tried various admixtures ; and recom- 
mends as the best equal parts of liquor calcis and oleum morrhuse. These, he 
says, when well shaken together, do not subsequently separate readily, but re- 
main in the form of an emulsion, thick and of a milky hue. 



1862.] 



Materia Medica and Pharmacy. 



215 



"Here," says Dr. W., "in addition to the tonic and sedative action of the liq. 
calcis (in itself so well suited to the many forms of disease in which cod-liver oil 
is recommended), a white-coloured, light, very palatable medicine is obtained 
(perhaps somewhat less disagreeable in its odour than the pure form, owing to 
the deodorizing action of the liq. calcis), easily rolling over the palate, and, 
when taken with a little sherry or orange wine, almost devoid of the oily taste, 
and combining, perhaps in the highest degree of all formulae that I have as yet 
tested, the advantages of the mode of administration which I now advocate. 

" The addition of a few drops of Condy's fluid to the mixture of liq. calcis and 
ol. morrhua3, sufficient only to render it of a greenish-yellow tint, rendered it a 
little less odorous, and, perhaps, more palatable. I am unable to say whether 
such addition would ozonize the oil, and thus render it more beneficial. The 
advantages gained by the mode of administration in other menstrua are : — 

" 1. The minute subdivision into globules, rendering it thereby more palatable, 
easily swallowed, and less likely to adhere to the mouth and fauces. 

"2. A saving to the stomach of the labour of disintegrating and minutely 
subdividing the oil, similar to that effected by the teeth in the trituration of 
solids, both ingesta being thus rendered easy of digestion and assimilation. 

" 3. The admixture of air-bubbles with the food is believed by many physio- 
logists to assist digestion ; this occurs to a very great extent during the shaking 
of the medicine, which should always be performed in a separate bottle at least 
twice as capacious as the dose, previous to its being taken. 

"4. It may be possible that the friction of the globules during the shaking 
may develop a portion of electricity in them, giving thereby a tonic character ; 
but this I leave to electrologists to determine. 

"The microscopic characters of the mixture of liq. calcis and ol. morrhuae, 
recently shaken together, are as follows : Oleaginous globules in a minute state 
of subdivision, pellucid, of a pale violet tint, many of them as small as milk glo- 
bules, but many of larger size, having but little tendency to run together into 
larger globules, with numerous air-bubbles intermixed." — Med. Times and Gaz., 
April 19, 1862. 

13. NeiD Preparation from Gliloroform. — Dr. Thomas Skinner, of Liverpool, 
calls attention to two physical properties possessed by chloroform, viz : 1. Its 
solubility in alcohol, and subsequent miscibility in water. 2. Its miscibility, if 
not its solubility, in water. 

Lately, while engaged experimenting in order to ascertain the probable com- 
position of Davenport's chlorodyne, Dr. S. accidentally discovered the following 
valuable facts : — 

" 1. If chloroform be dissolved in rectified spirit of wine, of specific gravity 
.838, at 60^ Fahr. (L.P.), in the proportion of from one to sixteen minims of chloro- 
form in a fluidounce, the resulting liquid is entirely and freely miscible with 
water in all proportions. On adding minim by minim of chloroform to the 
measure of thirty or thirty-two minins to the ounce of the mixture, the solution 
ceases to be miscible with water in any proportion : the chloroform sponta- 
neously precipitating in small globules, which ultimately coalesce. 

-"2. If chloroform be added to distilled or any good drinking water, in the pro- 
portion of half a fluidrachm to a pint (twenty fluidounces), and briskly agitated, 
the resulting liquid is perfectly clear and bright, and no globules of chloroform 
are precipitated, nor can any be detected with the microscope by a power 
equal to 250 diameters. On adding more chloroform gradatim, the point of 
saturation is not arrived at until the proportions are a fluidrachm to a pint of 
water. Sixty-four minims to the pint render the mixture quite opalescent, and 
much of the chloroform is precipitated. At the point of saturation, a drop of 
any essential oil shaken with the mixture will determine the separation of the 
chloroform. If the whole fluidrachm of chloroform be added at once to a pint 
of water, and shaken, the resulting liquid will not be so clear as when it is added 
gradually. 

"Bearing these interesting facts in mind, I resolved to put them to some prac- 
tical use ; and I beg to suggest the propriety of there being two new officinal 



216 Progress of the Medical Sciences. [July 

preparations of chloroform, the names and formulae for which shall be as fol- 
lows — 

" Spiritus Formyli Terchloridi (commonly called chloric ether) : Chloroform. 
5v ; rectified spirit of wine, sp. gr. .838 (L. P.), Oj. Mix. Dose, ^ss to gij. 

Mistura Formyli Terchloridi (or chloroform julep) : Chloroform, 3ss; pure 
water Oj. Mix thoroughly with brisk agitation, for a minute or two, in a vessel 
capable of containing double the quantity. Dose, .f ss to ^ij. 

" Either preparation may be prepared from the methylated chloroform ; but 
hitherto I have preferred the unmethylated for administration by the 'prima via. 
A chemical nomenclature has been chosen, in deference to the possible and not 
improbable fears of the patient." — DuUin Med. Press, May 21, from Brit. Med. 
Journ. 

14. Vesicating Collodion. — Mr. C. R. C. Tichborxe remarks {Pharmaceutical 
Journcd) that " amongst the many epispastics which have been introduced from 
time to time, cantiiarides has remained pre-eminent — its certainty, and compara- 
tive freedom from pain, being its special commenders. As direct and prolonged 
contact with the skin is necessary to produce a vesicle, many substances have 
been in use as an excipient for the application of the vesicant. Some of the 
preparations in use at present are fluid, whilst others are applied- in the form of 
plaster or ointment. In the first instance, if the desired effect is not produced 
instanter, rubefaction is the only result, an insufiScient amount being left upon 
the surface to produce a blister. Vesicating collodions are preparations which, 
after evaporation, leave a thick coating upon the cuticle, containing a certain 
quantity of irritating principle : these may be considered in their actions as 
intermediate between the fluid and solid preparations, combining, as they do, 
the properties of both. It is our especial vocation on the present occasion to 
take into consideration the construction of a formula for the collodium vesicans. 
This preparation, although constantly used by some very extensive practitioners, 
is far from being generally introduced, which may be accounted for from the 
circumstance that there is no authorized formula for its preparation, if we 
except M, Altigner's cantharidal ether and collodion, one to two parts of the 
latter for children. Each maker has then his own formula, which might be 
excellent, or vice versa, as the case may be. It will be our endeavour to pro- 
vide a formula which shall have suSicient strength to produce immediate vesica- 
tion, at the same time having a due regard to the economy of the method. To 
insure prompt action, it is not only necessary to introduce a sufficient quantity 
of blistering material, but it is also requisite that the excipient, or film in which 
it is applied, should be permeable enough to allow the active principle to transude 
freely through it. The tough and contractile film left by the ordinary collodion 
is almost worse than useless, as immediately on drying, the cantharidin at the 
surface and in direct contact alone exerts any beneficial effect ; an ordinary 
blister might be applied for any length of time, without producing a sensible 
result, if a dry film of plain collodion be interposed between the blister and the 
cuticle. 

"First, then, let us examine the texture of a collodion film, to mark its appli- 
cability in the present case. If we pour upon a glass slide some recently pre- 
pared collodion, and then examine it by the microscope, it will present the fol- 
lowing appearance: A pretty homogeneous and smooth ground, but running 
through which are slight ridges, which produce large honeycomb markings. 
These ridges are caused by the quick evaporation of the ether ; the whole is 
interspersed with filaments of partially disorganized cotton in a semi-gelatinous 
state. However carefully the cotton may be prepared, it is next to impossible 
to get rid of these fibres, some portion always escaping the perfect action of the 
acids. If we can add a small quantity of glacial acetic acid to the collodion, we 
shall find the character of the film greatly changed. From the slower evapora- 
tion the honeycomb ridges are no longer palpable, whilst the solubility is so 
much increased that the filaments are found to have disappeared. This film is 
perfectly uniform, but it presents this peculiarity, that it gradually dries into a 
muss of jelly like globules, which, however, possess but little cohesion ; when 
dry, it is very short, for if the finger be run up the glass, instead of leaving it as 



1862.] 



Materia Medica and Pharmacy. 



217 



a tougli skin, it collects as a moist crumbled mass. Having- so far seen that 
the glacial acid, besides destroying the contractility, gives it the properties of 
porosity and slowness in drying, it follows that such a collodion is particularly 
suited for the application of any vesicant which- we may intend to apply, instead 
of being a varnish which hermetically seals up the active matter. Glacial acetic 
acid is one of the best direct solvents of cantharidin with which we are acquainted. 
Pure cantharidin was found to be very soluble in that acid, a saturated solution 
depositing it unchanged on evaporation in hard mica-like crystals. The prin- 
ciple then that we propose is, to exhaust cantharides by a mixture of ether and 
acetic acid, and to convert these into a collodion by the addition of gun-cotton. 
Take cantharides ,^vj ;' Ether from methylated spirits f^xiij, or q. s. ; Glacial 
acetic acid f^ij ; Gun-cotton ^ss; Methylated spirits of wine f^vij, or q. s. 

" The cantharides, coarsely powdered, are placed loosely into a displacement 
apparatus, the flow of which can be regulated by a tap ; upon this is poured the 
ether and acetic acid, previously mixed together ; after the whole lias passed 
through, it will be found that the debris has retained by absorption seven fluid- 
ounces, which must be displaced by the gradual addition of an equal bulk of 
methylated spirits. If properly done, there is not the least danger of the ad- 
mixture of the spirits with the percolated menstruum, as the animal substance 
of the flies swells considerably under the prolonged influence of the spirits of 
wine, so that the same bulk will be insufficient to quite displace the ether. The 
ethereal solution should then be made to measure exactly f Jxv, by the addition 
of a little spirit, and may then be converted into collodion by the addition of the 
gun-cotton. Mylabris cichorii, treated in the same manner, gives even a more 
powerful vesicant than the cantharides. These flies, which constituted the 
iDlister of the ancients, are, I believe, to be procured in great profusion in India. 
The percentage of cantharidin is larger in these flies than in the cantharides, 
but they resemble them in all respects excepting their physical appearance. 

The most effectual method of using the collodion is as follows : The part 
upon which the vesicle is to be raised should be painted with the vesicant to 
the desired extent, bearing in mind that the blister produced always extends to 
about one-tenth of an inch beyond the margin of the space covered by the col- 
lodion. Care should also be taken that there is a considerable thickness of 
collodion upon the surface. To insure this the brush should be passed over 
and over again until about gss has been used to the square inch, or less when 
operating upon a tender epidermis. It is desirable to place a piece of oil-silk, 
or, what is still better, a piece of sheet gutta-percha, two or three inches larger 
than the surface of the intended blister ; the gutta-percha is not spoiled, whilst 
it hastens considerably the action of the collodion.^ 

"In ten minutes, or a quarter of an hour if the cuticle is hard, the collodion 
should be wiped off with a little cotton-wool moistened with ether, when the 
blister will almost instantly rise. The principles which advocate the use of the 
collodion may be enumerated as follows : Cleanliness, ease in applying to any 
wrinkled or jointed part, where the ordinary blister would be likely to be dis- 
placed, prompt vesication, and safety from strangury. Any of these properties 
would be sufficient individually to recommend its employment in preference to 
the- other preparations." 

15. Solid Creasote. — M. Stanislaus Martin remarks [Bulletin Generale de 
Tliiraideidique) that creasote is much employed as a popular remedy in the 
case of pain produced by caries of the teeth, but as the fluidity of this product 
is very great, its use often causes, in the mouth of persons using it, effects of a 
serious nature, which might be avoided by solidifying it in the following man- 
ner ; R. — Creasote, part xv ; collodion, part x. M. 



^ Two ounces more cantharides to tlie above proportions, make a very powerful 
collodion. 

2 The action of the gutta-percha is easily explained, by its stopping the evapo- 
ration of the exhalations of the skin ; in this manner the scarf-skin is rendered 
moist and permeable, the ordinary dry and harsh texture of the skin militating 
greatly against the production of a vesicle. 



218 



Progress op the Medical Sciences. 



[July 



The collodionized creasote has the consistence of jelly, and is used in the 
same manner as the simple substance. It has, however, this adrantao-e, that it 
forms a varnish, seals up the orifices in the carious tooth, and prevents the 
atmospheric air from reaching the dental nerve, 

Creasote is known to coagulate albumen, and it is probably to that property 
that its astringent and haemostatic action is due. "We think that the new form 
which we have given to this substance will allow surgeons to use it whenever 
they wish for a stimulating agent combined with isolated action. — Glasgow 
Medical Journal, April, 1862. 

16. Inefficiency of Hyoscyamus as nsnally prescribed. — M. Doxovax thinks 
that unnecessary caution is taken by physicians who administer tincture of 
henbane in doses of one or two drachms. He and some other persons have 
each taken an ounce of the tincture without any effect, the tincture having been 
prepared from the plant in its cultivated state, its wild state, dried, recent, and 
grown in various places in the British Isles. M. Hirtz informs us [Bull. G6n. 
de Th^rap.) that the extract of the leaves of hyoscyamus was given to patients 
in the dose of 50 to 75 centigrammes a day with results only slightly marked, 
and even these rather inconstant; a gramme (15.43 Troy grains) was sometimes 
given without any observable effect. 

In order to compare this result with his own. jSE. Donovan evaporated one 
ounce of the tincture (the same as had already served for his former experiments) 
until it assumed the usual consistence of extract of hyoscyamus. The evapora- 
tion was conducted at a very low heat, and the weight of the extract ascertained 
with great care ; it weighed 8.4 grains. This is very little more than the half of 
the dose of the extract which M. Hirtz administered without any observable 
effect. "I might, therefore," says Dr. D., "have made the dose of the tincture 
taken by myself and friends at least two ounces without any discoverable result. 
If two ounces had no effect, three ounces could not have much, unless it produced 
intoxication. In fine, I venture the opinion that tincture of the leaves of hyos- 
cyamus should be expunged from the Pharmacopoeia. Those physicians who 
venture on two-grain doses of extract of henbane will learn with interest that 
M. Hirtz gave fifteen and a half grains without any effect. His were clinical 
experiments, and therefore afforded the best opportunities for observation. I 
believe the case would be very much otherwise if the seeds were used instead 
of the leaves."— Dw&. Ifed. Press, May 28. 1862. 

[It is difficult to reconcile this statement with the case communicated by Dr. 
Keating to the Philadelphia College of Physicians (see number of this J ournal 
for July, 1858, p. 96), in which very profound and alarming narcotism followed 
the administration of three grains of Tilden's extract of hyoscyamus, or, at 
least, what was sold and labelled as that article.] 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

17. On the Exhibition of Food in Typhoid Fever. By M. Herard. — The 
following remarks made by M. Herard. in a clinical lecture at the Hotel Dieu, 
at Paris, are of particular interest at the present time, especially to the medical 
officers of our army hospitals : — 

" The treatment of typhoid fever is of course different according to the theory 
adopted on the nature of the disease. The practitioner who views in typhoid 
fever follicular inflammation of the intestinal tube, an ulcerous affection of 
Peyer's glands, and consequent absorption of poisonous fluids calculated to 
induce a septic condition, consistently prescribes antiphlogistic remedies in the 
incipient stage, and tonics in the more advanced period of the disease. Like- 
wise, those who conceive that the decomposition of the local secretions is the 
primary cause of the infection of the system act consonantly with their theory 



1862.] 



Medical Pathology and Therapeutics. 



219 



in systematically exhibiting emeto-cathartics and laxatives. In these opinions, 
however, M. Herard does not participate ; while taking into serious account 
the intestinal eruption, which, like that of smallpox, induces a certain amount 
of circumambient inflammation, he cannot admit this to be the proximate cause 
of typhoid fever. No concordance can be traced between this anatomical change 
and the general condition of the patient, the gravity of which must be acknow- 
ledged to be entirely independent of the local injury. Hence the latter cannot 
be taken for a guide in the choice of the medication most appropriate to a fever 
in which the collapse of vital power and the obvious tendency to hemorrhage 
and mortification point most distinctly to a primary alteration in the composi- 
tion of the blood. M. Herard does not deny that an emeto-cathartic may be 
proper to remedy the foul state of the primse vise, so common in the early stage 
of typhoid, but he can neither concede to aperients, to venesection, nor to local 
bloodletting, the privilege of being the exclusively appropriate modes of treat- 
ment of the disease. 

" In typhoid fever M. Herard proceeds as follows : — 
In moderate, and a fortiori in mild cases, he refrains from any active inter- 
ference calculated to debilitate the patient, and to cause the disease to assume 
the dangerous form which justly occasions so much dread. M. Herard pre- 
scribes an emeto-cathartic, one or two doses of saline aperients, a few baths if 
the skin be very hot and dry, and wine and water. Baths restore the functions 
of the skin, and usually induce sleep. In the adynamic variety he resorts to 
tonics, stimulates the system with Malaga or Bordeaux wine, either in drinks 
or in enemas, prescribes from half a drachm to a drachm of powdered cinchona 
bark, in cofi*ee without milk, and also recommends various stimulants, such as 
musk, camphor, acetate and carbonate of ammonia. He causes, at the same 
time, the eschars to be covered with powdered Peruvian bark, and requires from 
the nurses the most strict attention to cleanliness. In the ataxic form, the most 
fatal of all, bloodletting, leeches, blisters, are unavailing; all remedies seem 
powerless. In order, however, not to appear entirely inactive in cases of such 
dire gravity, he prescribes stimulants, dry cupping of the extremities, blisters 
to the nape of the neck, and cold effusions cautiously administered. In the 
thoracic form, which this year has been the most prevalent, blistering and cup- 
ping, with scarification, are the remedies which M. Herard has chiefly resorted to. 

" The above is a brief summary of the treatment appropriate to typhoid ; but 
in the management of the disease the all-important, the capital question is that 
of food. 

" Despite the wise precepts of Hippocrates, said M. H6rard, despite the recent 
researches which have only confirmed their value, we are still all more or less 
influenced by the now exploded doctrine of irritation. The terms fever and 
food still appear to imply a contradiction, although it is but too certain that in 
typhoid prolonged abstinence leads to the most disastrous results. 

" Some ten years ago, M. Herard was in attendance on a lady sufi'ering from 
a moderately violent attack of the malady under consideration. Cerebral 
symptoms having set in, a consultation took place, and an eminent professor of 
the school of medicine recommended absolute abstinence from food, and the 
daily exhibition of one or two glasses of seidlitz water. The latter part of the 
prescription M. Herard took upon himself in some degree to modify, but the 
abstinence was strictly enforced. After two or three weeks' treatment the pulse 
rose from 110 to 120, nocturnal agitation set in, with wandering, delirium, vomit- 
ing, and diarrhoea. On the following days the frequency of the pulse increased 
to 145, vomiting became incessant, the diarrhoea incoercible, the delirium con- 
stant ; the tongue was red, and thrush appeared over the entire mucous lining 
of the mouth. Another consultation was deemed expedient ; the three gentle- 
men whose opinion was requested viewed the case in a different light. One 
pronounced the patient to be suffering from softening of the stomach ; the 
others, struck by the pinched countenance, the emaciation of the entire body, 
and the cough which had set in in the incipient stage of the disease, believed in 
galloping consumption, and proposed cod-liver oil. M. Herard, who had long 
been acquainted with the patient, found it impossible to adhere to any of these 
views, and, moreover, unable to venture, under the existing circumstances, on 



220 



Progress of the Medical Sciences. 



[July 



the exhibition of cod-liver oil, surmised that the previous protracted abstinence 
might possibly have some share in the aggravation of the symptoms, and deter- 
mined upon trying the effects of nutriment. He found it almost impossible at first 
to carry out this plan, and it was vp^ith the utmost difficulty that a few drops of 
iced beef-tea were swallowed. He succeeded by dint of perseverance, however; 
and when the food remained on the stomach, and in proportion to its increase, 
the pulse fell from 145 to 130, 120, 115, and 100 ; the delirium yielded, and, in 
short, the patient recovered. 

" M. Herard is convinced that similar cases are of not unfrequent occurrence, 
and that the dangerous symptoms of the ataxic form of typhoid are often induced 
by the strict abstinence previously enforced. In a highly interesting paper on 
the subject, M. Marotte has established that vomiting, diarrhoea, and delirium, 
more especially the latter, are characteristic of starvation. In a lecture recently 
published, M. Trousseau already pointed out the striking analogy existing be- 
tween the more serious symptoms of typhoid and those of autophagy consequent 
on protracted abstinence. The valuable experiments of M. Chossat may further 
be adduced in illustration of the theory which accounts for this extremely im- 
portant fact, and must lead to a complete change in the treatment of typhoid 
fever. 

" The expression we advisedly use is treatment, not diet. Nutriment here 
must be viewed not as an adjuvant, but as the principal medical agent. It has 
been objected that if food be exhibited, indigestion and emesis must follow. 
This is correct after protracted abstinence, and proves the necessity of early 
alimentation, otherwise the digestive powers of the stomach become impaired 
and the food is rejected. Opponents of the method further urge the impossi- 
bility of venturing on the exhibition of nutriment, on account of the deposits 
which necessarily exist on the mucous surface of the stomach, and poison the 
breath of the patient by their decomposition. Now these deposits are frequently 
but one of the consequences of abstinence, and if the tongue and gums are 
cleansed with a brush impregnated with honey of roses or syrup of mulberries, 
the sores do not form again after the ingestion of food. M. Herard had recently 
under his care, at Lariboisiere, patients who have fasted for three weeks, and 
who displayed marked distaste for any kind of nutriment. The gums were 
covered with sores, the breath was foul ; but after cleansing the mouth and 
scraping the tongue, food, which these patients were compelled to take, pro- 
duced its usual salutary effects, and in a few days was accepted with pleasure 
and with the most beneficial results. M. Marotte relates the case of a young 
man, aged twenty, who, at first compelled to eat, soon took his food with plea- 
sure, and ultimately recovered in an unhoped-for manner. The propriety of 
feeding patients suffering from typhoid has also been questioned in another re- 
spect ; the presence of intestinal ulceration, of tympanitis and diarrhoea had 
been viewed as a direct counter-indication to the exhibition of nutriment, and 
as the probable cause of the most perilous symptoms in case this method was 
resorted to. This fear is entirely chimerical. You must not, moreover, forget 
that the cachectic condition of the patients is the greatest possible obstacle to 
the healing of the ulcers, and that the latter are portals through which poison- 
ous principles will most readily be admitted. Subjects affected with intestinal 
ulcerations should be fed, and the ulcers, nevertheless, decrease in size, and heal 
In the same manner as bed-sores, so common under similar circumstances, yield 
to the influence of generous diet. Some short time ago, a woman was admitted 
into the H5tel-Dieu, on the twentieth day of a typhoid fever complicated by 
extensive mortification in the region of the sacrum. Nutriment, appropriate in 
nature and in quantity, was gradually exhibited, and the wound speedily lost its 
pale aspect, assumed a more healthy hue, granulated, and healed. Had absti- 
nence from food been here persevered in, she would very probably have perished ; 
but a contrary course was followed, and she recovered rapidly. Another bene- 
ficial effect of nutriment is to shorten the duration of the convalescence^ which 
formerly was interminable after putrid fever. Patients, who have received ade- 
quate support during the progress of typhoid, have been known to pass without 
any transition from disease to health, and to walk in the garden of the hospital 
on the very first day they left their bed. 



1862.] 



Medical Pathology and Therapeutics. 



221 



" It is not unimportant to inquire what should be the nature of the nutriment 
allowed. It was formerly the custom to exhibit food when only the feverishness 
had subsided, and it sometimes unfortunately happened that the delay was so 
long as to render the food superfluous. Other practitioners prescribe broth, 
under the impression that broth is sufficient support to the system. Broth is 
doubtless a nutrimental substance ; we are all acquainted with its restorative 
powers, but we must not exaggerate its value. M. Bouchardat demonstrates 
that a quart of broth contains but six drachms of solid nutriment, two of which 
are saline ingredients ; subtract from the remaining four drachms a certain amount 
which passes through the kidneys, and you will doubtless agree with me that the 
residue affords but insafiicient support to the system. 

" M. Herard proceeds then to describe his mode of administering food in 
typhoid. Soups are, in his opinion, the best articles of diet; egg-flip is often 
useful, and contains a large proportion of nutriment especially applicable in the 
thoracic variety of the disease. Jellies are also advantageous, and when, on 
account of their volume, soups are not easily digested, the professor, even at an 
early period of the fever, does not hesitate to recommend the suction of a mutton- 
chop. Patients, whose stomach rejects the weakest broth, frequently digest 
with facility a small piece of broiled beef or mutton. He is no friend of the 
debilitating tisanes and diet-drinks usually prescribed, but agrees with M. Mon- 
neret in the utility of wine, as a stimulant of the vital powers. The beverage 
he recommends is weak wine and water, and, in addition, eight ounces of Bor- 
deau or bark wine, to be taken in enemas if necessary. When the digestive 
powers of the stomach have been much impaired, he conceives that pepsine, 
acting as a kind of ferment, promotes the assimilation of the food and gives the 
gastric viscera time to recover their secretive action, the patient, in the mean- 
while, not suffering from the efiect of injurious abstinence. Fifteen grains of 
pepsine may therefore be exhibited in a wafer with animal food. 

" In addition to these physical restoratives, M. Herard has recourse to moral 
agency. The greater numlDer of individuals sufifering from typhoid fever in the 
hospitals are young people of both sexes, not only strangers in Paris, but often 
foreigners. Their isolated condition, combined with the knowledge that they 
are labouring under serious illness, has much to do with the low condition into 
which they speedily fall. Hence the importance of encouraging such patients 
by a kindness of manner and of language calcukted to improve their moral 
condition, and to counteract the unfavourable influence exercised upon their 
system by the distressing circumstances under which they happen unfortunately 
to be placed." — Journ. Pract. Med. and Surg., May, 1861. 

18, Quinine as a Prophylactic of Fever. — The powers of quinine as a pro- 
phylactic, remarks Dr. Smart, in his account of the climatology, etc., of Hong- 
Kong, were proved extensively among the crews of the gunboat flotilla employed 
oh the Canton Kiver. Although those little vessels were constantly on river 
service, often remaining the night with their bows driven on the mudbanks, their 
crews sleeping on deck in preference to the close heated atmosphere of 'tween 
decks, having no medical officer on board, and thus receiving merely an eleemo- 
synary medical supervision from the larger men-of-war they came near, yet they 
seemed not to suffer disproportionately from malarious fevers, excepting those of 
the intermittent type. Their comparative exemption I considered to be due to 
the abundant supply of quinine wine ordered for them by the medical inspector 
of the fleet. On the slightest occasions of indisposition they had. recourse to 
their commanding officers, who held the quinine bottle at hand, in the preventive 
and curative powers of which the seamen seemed to have the utmost confidence. 
— Trans. Epidemiolog . Soc. of London, May, 1861. 

19. Clinical Inquiry into the Use of Iron in Pulmonary Consumption. — In 
our No. for April last (p. 523) we gave results of the clinical trials by Dr. R. 
P. Cotton on the action of steel in phthisis. 

More recently {Bled. Times and Gazette, March 22, 1862) Dr. James Jones, 
Physician to the Infirmary for Consumption, in Margaret Street, has published 
the results of his clinical observations on the same subject. 



222 



Progress of the Medical Sciences. 



[July 



Passing over the writer's physiological and pathological speculations, we shall 
give his practical deductions as of most importance. 

" The mode of administering iron in phthisis'' Dr. Jones conceives to be "a 
subject of the greatest importance to its success as a remedy. In prescribing it 
it is necessary that we should bear in mind the object to be accomplished by its 
exhibition, the supply of the deficiency of one of the normal elements of the 
blood. We must give iron as a blood food, carefully regulating the quantity by 
the requirements of that fluid. When iron is given in over-doses it soon induces 
headache and derangement of the organs of digestion. There is nothing more 
common than to hear from patients that steel has always disagreed with them. 
This intolerance of iron may generally be referred to two causes : Firstly. The 
unfitness of the preparation. Secondly. The excess of the dose. 

"With regard to the first of these points it is important that the preparation 
of iron which is used should have the following qualities : First. Perfect solu- 
bility. Second. A composition in harmony with the digestive fluids, the blood, 
and the other fluids of the body. Third. Compatibility with such drugs or medi- 
cines as may be required by the varying phases of the disease. The perchloride 
of iron possesses all these properties. It is perfectly soluble. Chlorine is an 
abundant and important element of the principal fluids of the body. It is thera- 
peutically compatible with most of the medicinal substances used in the treat- 
ment of phthisis, such as quinine, morphia, chloric ether, hydrochloric acid, 
phosphoric acid, chlorate of potass, etc. I have tested experimentally the ma- 
jority of the preparations of iron, and find none so generally to answer as the 
perchloride. I have found it occasionally to cause nausea, but this soon ceased 
on lessening the dose. I have used the pyro-phosphate of iron in several cases 
where the perchloride was objected to. Its effects have satisfied me that it is in 
many respects equally as useful as the perchloride. It appears to possess neu- 
rotonic properties, and to act very similarly to a combination of perchloride of 
iron with phosphoric acid. The syrup of superphosphate of iron introduced by 
Dr. Routh is also a useful preparation. Secondly, with reference to the dose. 
I have reason to believe that the disuse into which the preparations of iron have 
fallen in the treatment of consumption is mainly referable to the custom of pre- 
scribing it in large doses. Disorder of the organs of digestion, also headache, 
and other symptoms of either hypersemia or of the presence of an unnecessary 
substance in the blood, are the consequences of its excessive use. 

"In healthy blood the quantitative correlation of its elements is pretty con- 
stant, but in the cachexia of tuberculosis this condition is disordered, and the 
object of our treatment should be the restoration of the normal relation of its 
elements. 

" Thus, in using iron as a curative agent, the quantity should be sufficient, 
and only siifficient, to supply the waste of that element shown by the diminished 
numbers of red corpuscles. Any excess of this quantity tends to embarrass the 
system by the presence of an unnecessary element. It is obvious that the dose 
must vary according to the requirements of each case. I am convinced, by 
experience, that the dose generally given is far too large. When the state of 
ansemia is strongly pronounced, the dose of a ten per cent, tincture of perchlo- 
ride of iron may be fifteen minims three times a day, but it will soon be, found 
necessary to reduce it considerably. In a large number of cases, from three 
to five drops twice or three times a day will be found sufficient to meet the 
requirements of the system. In these small doses the remedy maybe used for a 
long time. I have in many instances exhibited it continuously for more than 
twelve months without the occurrence of any of the symptoms mentioned as 
interfering with its use. 

"In order to derive the full benefit from the use of iron in phthisis it must be 
continued for a long time ; for it is not only necessary to establish a healthy 
sanguification, but also to maintain it. The condition of cachexia attending 
tuberculosis tends to lower the standard of the blood, and this tendency is con- 
stant. If by any means a healthy condition of the blood be produced, it cannot 
long be maintained without the continued use of hsemagenetic agents ; hence 
the necessity for the exhibition of iron over a long period. I would dwell upon 
this point as one of paramount importance. It is in the continuous use of it 



1862.] 



Medical Pathology and Therapeutics. 



223 



over a long time — one, two, three, any number of years — as long as not only the 
condition of, but the tendency to, tuberculosis exigts, that its value as a remedy 
is manifested. 

"The improvement in the state of health which takes place during the exhi- 
bition of perchloride of iron shows itself in the increase of bodily vigour and 
capability of undergoing fatigue, the improvement of the appetite, and the abate- 
ment of the well-known symptoms of impaired digestion, such as flatulency, heart- 
burn, acidity of the stomach; in the diminution or cessation of night perspiration, 
and of the tendency to perspire on slight exertion ; in the abatement in the 
severity of the cough ; in the decrease in the quantity of expectoration, and in 
the less frequent return or complete absence of haemoptysis, 

" "While endeavouring to show the great importance of iron in the treatment 
of consumption, I wish to guard against the possibility of being misunderstood. 
My desire is merely to direct attention to its claims as a powerful agent in the 
treatment of that disease, to point out the proper mode of its administration, 
and to assign to it its place in the materia medica for consumption. I do not 
propose the use of iron as a substitute for cod-liver oil. Each of these agents 
has a distinct function to perform in aiding nutrition and promoting a healthy 
sanguification. In a large number of cases both are necessary, each acting a 
part peculiar to itself, yet complementary to the other." 

20. Chlorate of Potassa in Phthisis. — Dr. R. P. Cotton has experimented 
with the chlorate of potassa on 25 patients in the Hospital for Consumption, 
Brompton, and his results are by no means favourable. 

" The generally acknowledged tonic, antiseptic and upholding influences of 
the chlorate of potassa, have caused," he observes, "this agent to be rather 
extensively tried in consumptive cases. The results, however, have been very 
variously stated ; but, in a recent number of the Dublin Quarterly Medical 
Journal, a physician of Belfast has unhesitatingly brought it forward as a 
specific for pulmonary tuberculosis, at least in the first and second stages of 
that disease. 

" Of the twenty-five cases for which I prescribed it, fifteen were males and ten 
females. Eight were in the first stage, eight in the second, and nine in the third 
stage of phthisis. They varied in age : one had reached fifty ; but the rest were 
from twenty to thirty years. Notes were regularly taken by Mr. Harington, 
resident clinical assistant. 

" Of the entire number, five improved considerably, four improved a little, and 
sixteen seemed to derive no advantage. Of the latter number, four, at least, 
may be said to have been more or less benefited when the chlorate was ex- 
changed for some other tonic. 

" The period during which it was administered varied in different cases. In 
this, as in the preceding experiments, my habit has been to continue the same 
treatment for at least three weeks. If, at the expiration of that time, very little 
or no progress has been made, I have tried something else ; but whenever there 
has been encouragement to proceed, I have done so. My notes record that the 
chlorate of potassa was taken in five cases, for periods varying from six to ten 
weeks ; the average being four weeks. The dose was ten or twelve grains three 
times a day. 

" In twelve cases cod-liver oil was occasionally, but not quite regularly, taken 
at the same time. It would, of course, have i3een more satisfactory had the 
chlorate in every instance been administered alone ; but many patients on enter- 
ing the hospital are already so practically acquainted with the good eSfects of 
the oil, that it would be cruel to deprive them of its use, whilst in such cases 
the attempt to do so would in all probability only prove abortive, for I have 
many times discovered that patients for whom I have not prescribed cod-liver 
oil have very significantly testified to its usefulness by taking it clandestinely. 
In analyzing those cases in which the oil had been taken, I find that six belong 
to the list of nine more or less improved patients. 

"Nine increased in weight whilst taking the chlorate, seven lost weight, and 
nine underwent no change. Of the nine who gained in weight, six belong to 
the number who had also taken, more or less, the cod-liver oil. 



224 



Progress of the Medical Sciences. 



[July 



"Of the improved cases, three were very decided, the patients having ex- 
pressed themselves as feeling better than they had done for many months ; two 
of these, however, belong to the class who had taken the oil. It was generally 
observed that those patients in whom there was any perceptible improvement 
were of broken down and cachectic constitution; indeed, just in that condition 
in which, without regard to their being phthisical, the chlorate of potassa might 
very hopefully have been prescribed. 

" The preceding facts, taken in connection with the very potent influences of 
improved sanitary and dietetic arrangements to which all the patients were 
subjected on entering the hospital, would seem to justify the following conclu- 
sions : — 

"1. That chlorate of potassa has no specific action upon consumption. 

" 2, That its usefulness, even as an auxiliary in the general treatment of 
phthisis, is very questionable, and is probably limited to that cachectic class of 
cases in which it and allied remedies are so often serviceable." — Med. Times 
and Gazette, May 24, 1862. 

[These conclusions are confirmatory of those of Dr. Flint, whose interesting 
report will be found in our No. for October, 1861, p. 321.] 

21. Delirium Tremens ti^eated hy Large Doses of Digitalis. — In our No. 
for January last we quoted four cases of delirium tremens successfully treated 
by large doses of digitalis. Another case has been related [Med. Times and 
Ga%., April 26, 1862), which occurred at the Eadcliffe Infirmary, Oxford, under 
the care of Mr. Hester. "A drayman, aged 28, of very powerful frame, was 
admitted for a contused wound in the occiput, caused by falling backwards 
whilst intoxicated. The hemorrhage, which had been very free, was checked 
by the application of a little pressure ; and being put to bed he soon fell asleep. 
Next day he appeared to be suffering from the effects of his debauch, and, as 
he craved very much for a drop of beer, a pint of ale was allowed, which made 
him feel more comfortable ; but in the evening he was seized with a violent fit 
of epileptiform convulsion, which lasted for about ten minutes. Another half 
pint of ale was given to him. with the same result as before ; and during the 
night he had two slighter fits of the same character. 

On the second day he complained of pain in the head, and, his bowels being 
confined, a good dose of calomel and jalap was administered, to be followed by 
sulphate of magnesia every four hours, and cold applied to the head. His bowels 
were freely opened, and he was quiet throughout the day and the following night. 

" On the third day he became restless and fidgety, and was with difficulty kept 
in bed,- being frightened by some imaginary object which he said constantly 
pursued him. In the night he got out of bed, and had to be carried back by 
force, in spite of his most violent efforts to the contrary. A strait-waistcoat 
was applied, and half an ounce of tincture of digitalis given in water. He soon 
became quiet, muttering a sentence in low voice now and then, and continued 
so through the night, but did not get any sleep. Next day he was restless, and 
towards night became again very violent. A second dose of the digitalis was 
administered, and in a few minutes he fell asleep, and slept through the night 
and the greater part of the next day. After this he became very quiet and 
comfortable, and has progressed up to the present time very satisfactorily, the 
wound having nearly healed." 

Dr. MoRRELL Mackenzie has tried the tincture of digitalis in three cases of 
delirium tremens [Lancet, March 8, 1862) in the doses recommended by Dr. Jones, 
of Jersey, and in two of these cases death occurred, and in the other the digitalis 
had to be abandoned, and recourse had to stimulants and opiuni, under which 

the patient recovered. " One of these patients, W. P , aged twenty-eight, a 

potman, and an habitual dram-drinker, was admitted into the London Hospital, 
under the care of Dr. Fraser, at seven o'clock in the evening of the 6th of July, 
1861. Though he was fearful and highly tremulous, his case did not .appear 
unusually severe. On auscultation, there were no signs of cardiac disease, and 
half an ounce of the tincture of digitalis was accordingly prescribed. A nutri- 
tious diet was ordered, but no stimulants were allowed. An hour later the pulse, 
which was previously at 84, was reduced to 60 ; it was full and regular. At ten 



1862.] 



Medical Pathology and Therapeutics. 



225 



o'clock the dose was repeated, and the patient passed a quiet, though sleepless, 
night. In the morning another half ounce was given, and in the afternoon the 
dose was again repeated. On both occasions, about half an hour after taking 
the medicine, vomiting supervened. There was no increase in the renal secre- 
tion. The patient did not appear much distressed by the sickness, and in the 
afternoon he had a steady pulse of 68. During the day he became very restless, 
and, instead of being timid and subdued, was now fierce atid fearless, requiring 
powerful restraint. In the evening he was still more violent, and at nine o'clock 
the digitalis was again repeated, but this time only two drachms were given. 
Between ten and eleven, being now even more excited, it was determined to 
discontinue the digitalis and try opium ; but before the latter drug could be 
administered, after a short but violent struggle with his attendants, which at first 
appeared voluntary, but afterwards convulsive, the patient suddenly expired. 

" The following extract from the account of the post-mortem examination 
shows the condition of the heart after death, and perhaps some relation between 
the therapeutics and the pathology : ' Little fluid in the pericardium, in which 
the heart lay like a flaccid empty bag. To the touch, before removal, the cavities 
of the heart and large vessels seemed almost empty. On cutting across the 
great vessels, only a small quantity of dark fluid blood escaped : the whole heart 
felt flaccid, and its cavities did not contain half an ounce of blood.' I may men- 
tion that there was no appearance of disease in the brain or membranes, except 
that the dura mater was slightly adherent to the skull in the parietal and occipital 
regions. There were a few drachms of serous fluid in the lateral ventricles. 

" In the case of the next patient, who died after the administration of half an 
ounce of the tincture of digitalis (which was given to him by a practitioner 
shortly before he was brought to the hospital), the man was admitted in a semi- 
comatose condition, from which he never roused, and unfortunately his friends 
objected to an autopsy. 

" The third case was that of H. N , aged forty-five, a butcher, admitted 

under the care of Dr. Frazer, on the 14th October, 1861, with the usual symp- 
toms of delirium tremens; 'the hands and tongue were tremulous, and, though 
slightly excited, he was quite sensible.' The opiate treatment was adopted, but, 
no improvement taking place, it was determined to try digitalis. Within eleven 
hours the patient took an ounce and a half of the tincture of digitalis, in three 
half-ounce doses. Though the frequency of the pulse was diminished, the nerv- 
ous symptoms were aggravated ; and, from the report of Mr. Fred. Carter, it 
appears that ' an hour after taking the draught (the third dose) the patient be- 
came very troublesome and violent — so much so that he was removed to the 
attic and placed in a strait-jacket.' Opium in large doses was now prescribed, 
and the patient was put under chloroform, in order that the system might be 
more readily affected by the narcotic. On the 29th October, after taking five 
drachms of the tincture of opium in nineteen hours, he slept for some hours, 
and awoke quite collected. The effects of the digitalis were very similar to 
those produced in the potman who died, for in both the timidity of delirium 
tremens gave way to the fury of acute mania. 

" With regard to the cases recently reported in the medical journals, it appears 
from Dr. Harrison's letter in the Lancet of Feb. 15, that before any digitalis 
was administered the patient was ' quieter,' an admission which somewhat de- 
tracts from the supposed curative eff'ects of the digitalis ; and in the case reported 
by Dr. Duchesne, it is stated that ' it was a primary attack occurring in a young 
man of tolerably regular habits' — circumstances so favourable in themselves, 
that almost any remedy might be expected to prove especially useful. It is to 
be observed, too, that in both the cases recently placed before the profession 
large doses of opium had been previously administered ; and it is not difficult 
to suppose that an abnormal condition of the nervous system should have 
delayed the absorption of the narcotic, which, afterwards taking effect, pro- 
duced the curative results ascribed to the digitalis. 

"In conclusion, I may remark that 'the usual hospital treatment energetically 
pursued,' consisting of stimulants, nourishing food, and opiates, rarely fails ; and 
that it is seldom that a patient dies in this hospital from delirium tremens, unless 
his case is complicated with serious traumatic injury." 
No. LXXXYIL— -July 1862. 15 



226 



Progress of the Medical Sciences. 



[July 



22. Treatment of Pleurisy. — M. Trousseau rarely employs bloodletting in 
the treatment of pleurisy ; he scarcely ever cups even at the commencement of 
the disease. As an antiphlogistic, he prefers calomel in minute doses, adminis- 
tered, according to the method of Low, aconite and digitalis. A favourite mode 
of treatment in these circumstances is the following : calomel, a grain and a 
half, powdered sugar, a drachm and a half. To be carefully mixed and divided 
into twenty powders, of which one is to be taken every hour or every two hours. 
Tincture of aconite, and tincture of digitalis, of each fifteen drops ; ordinary 
julep, five ounces. A tablespoonful to be taken every two hours. The pleuritic 
pain may be relieved by the application of a compress soaked in chloroform, or 
in a watery solution of opium. The part having been rubbed for five minutes 
with the latter preparation, a moist rag is to be placed over it and covered with 
a piece of oiled silk. 

When pleurisy is complicated with eff'usion, M. Trousseau has never recourse, 
in order to favour the absorption of the serous fluid, to blisters, so generally 
used in this state. Blisters, and especially large blisters, present several dis- 
advantages ; they cause great suff'ering, and are often the cause of ecthyma, 
abscesses, boils, carbuncles, erysipelas, and other severe accidents. Not long 
ago, there was in the Hotel Dieu a patient who had been treated outside on 
account of pleurisy, and who, as the result of a blister, presented two abscesses 
of the thoracic parietes, so situated that they at first appeared to communicate 
with the interior of the chest, or to be symptomatic of caries of a rib. They 
had, however, been produced by the application of a blister, and on being dressed 
in the usual way soon healed. 

M. Trousseau's treatment of effusion varies according to its importance. If 
the amount is inconsiderable, he confines himself to the administration of digi- 
talis in doses of ten or fifteen drops, of diuretic drinks, quiet, and a light diet. 
If the effusion is consideifable and the pleurisy simple, he evacuates the fluid by 
means of thoracentesis. M. Trousseau does not allow himself, under these cir- 
cumstances, to be guided by the degree of oppression. He has actually seen 
two women, affected with enormous pleuritic effusions, die suddenly, without 
having experienced the least dyspnoea. One of these patients was a nurse, at 
the twelfth day of pleurisy ; she died while sleeping, and her countenance ex- 
pressed the most perfect calm. M. Trousseau is inclined to share the opinion 
of Aran, who recommended that the operation should be practised as soon as 
the effusion had reached the fourth rib ; in fact, in these circumstances he has 
never seen a bad result follow. However, he seldom operates until the fluid has 
reached the level of the clavicle. 

The operation is very simple ; the puncture is made in the fourth or fifth 
intercostal space. If there is no other means at hand to prevent the introduc- 
tion of air into the pleura, the wide end of the canula is plunged into the fluid 
which is flowing out. and this latter is itself an obstacle to the entrance of air. 
Thus practised, thoracentesis has always excellent results when the effusion is 
on the left side, that is to say, when the pleurisy is simple ; for Aran found, by 
clinical observations, that, ninety-five times in a hundred, pleurisy of the right 
side is secondary, being connected with tubercular disease of the lungs, while 
pleurisy of the left side is generally primary. 

In the case of tubercular pleurisy with effusion, thoracentesis maybe resorted 
to as a palliative, although necessarily with little chance of success. Topical 
applications are, however, often useful, particularly the repeated application of 
ioduretted preparations, and especially of the alcoholic tincture of iodine. — Ed. 
Med. Journ., April, 1862, from Journal de M^d. et de Chirurg. Prat., March, 
1862. 

23. Pneumonia in Infants. — M. Barthez, who is well known to the medical 
world by his valuable work on Diseases of Children, which he undertook in 
common with the late M. Rilliet, of Geneva, has lately given us an interesting 
account of his most recent experience on pneumonia in infants. From 1854 to 
1861 he has in hospital practice observed 212 cases of genuine pneumonia in 
infants, and only lost two patients, both of which were affected with bilateral 
pneumonia. One-half of the children suffering from inflammation of the lungs 



1862.] Medical Pathology and Therapeutics. 



221 



who came under M. Barthez's care were subjected to no treatment whatever; 
in a number of others the treatment was confined to an occasional purgative, 
emetic, or bath ; and only in one-sixth of the cas^s active remedial measures 
were resorted to. Besides these, M. Barthez has treated a large number of 
similar cases in private practice with similar results. He therefore concludes 
that genuine and non-complicated pneumonia in children is, at least as far as 
Paris is concerned, a mild disease, whatever may be the seat and extent of the 
inflammation, the seasons, and the years, and whether the medication employed 
be active, insignificant, or absolutely none. Double pneumonia is, however, 
more dangerous, as two patients died out of thirteen affected by it. The age of 
the patients was between two and fifteen years. Pneumonia complicated with 
other diseases, such as typhoid fever, tuberculosis, etc., is of altogether a differ- 
ent character. 

Concerning the duration of the several stages of the disease, M. Barthez 
remarked that if no treatment was pursued, resolution commenced between the 
sixth and eighth day from the commencement of the disease, and more especially 
on the seventh day ; in some cases, however, it began as early as the fourth or 
fifth day, or was retarded till after the eighth. 

A mild treatment produced no change in this respect ; and the disease being 
essentially benignant, M. Barthez rejects the antiphlogistic treatment altogether, 
so much the more as he has seen that several children who were treated with 
bloodletting, etc., made a bad recovery, and for a long time remained pale and 
emaciated. In only four patients he found it necessary to have recourse to 
repeated phlebotomies ; and in these instances resolution commenced on the 
fifth, sixth, seventh, and tenth days. If resolution has once begun, there is 
soon an end of the disease, viz., between two and six days, it being only seldom 
protracted from seven to ten days. This natural duration of the stage of de- 
crease is not sensibly altered by any treatment : but if the latter is very active, 
the patient does not find any benefit from it. Pneumonia in infants generally 
terminates in ten days or at most within a fortnight, if left to itself ; but if severe 
antiphlogistic measures are resorted to, the disease may be protracted. In 
double pneumonia a fortnight is generally the shortest term of the disease. The 
recovery is always most rapid in those children who have had no, or scarcely 
any medicine ; these almost invariably get well within a fortnight, while in those 
who have been actively treated convalescence often lasts from fifteen to thirty 
days. As regards the seat of the affection, resolution is quickest if the middle 
part of the lung is affected ; inflammation of the top and the base of the lungs 
has much the same duration. The general conclusion to be drawn from all the 
facts mentioned is, that careful attention should be given to hygiene, and that 
as little medicine should be prescribed as possible. Occasional emetics, purga- 
tives, warm baths, or bloodletting are in certain cases useful for relieving the 
pain in the side and the oppression on the chest. — Med. Times and Gazette, 
May 10, 1862. 

24. Treatment of Cancrum Oris. — Dr. Alexander Keiller read before the 
Medico-Chirurgical Society of Edinburgh (5 March, 1862) a highly interesting 
paper on the nature, causes, and treatment of cancrum oris. With regard to 
the character and value of the treatment which he considers ought to be had 
recourse to in this disease, he remarks : — 

"In the first or mildest form of stomatitis, viz., the simple foUicular variety, 
which appears either in the form of aphthce or superficial idceratiojis, little more 
is required than attention to the stomach and bowels ; for, by simply correcting 
any intestinal or gastric derangement, the follicular disease generally disappears. 
If local applications are necessary, borate of soda in solution, or solution of 
nitrate of silver (four or five grains to the ounce), will generally do all that is 
required. 

"In the second or idcerative form (which is of frequent occurrence, and if 
neglected, may prove in some cases serious), a tonic treatment is to be enjoined, 
and, above all, the administration of chlorate of potash, which Dr. West and 
others have called a specific in this affection. Dr. West gives it in doses smaller 
than those in which I usually prescribe it. I give ten grains every two or three 



228 



Progress of the Medical Sciences. [July 



hours, and, when combined with the local application of Condy's solution every 
second day, and the free administration of wine and iron, I have seldom required 
to do anything else, except of course to remove any loose teeth or alveolar exfo- 
liation acting as sources of irritation. 

"In the third and dangerous form, to which I have more specially been refer- 
ring, viz., the gangrenous form of stomatitis, the treatment is, like that of the 
others, twofold, local and constitutional ; the local being here, however, much 
more severe, amounting to absolute destruction or removal of the morbid tissues 
by cauterization ; the general or constitutional consisting in whatever will tend 
to build up and invigorate the system, such as quinine or other tonics, full diet 
with wine, together with ten-grain doses of chlorate of potass often repe?ited. 

" The great object to be kept in view is the perfect arrestment or total removal 
of the gangrenous action ; for, if we trust to the occurrence of a spontaneous cure, 
or allow the sloughing process to progress unchecked, which we are too apt to 
do on first seeing a case of this kind, we shall soon find it too late to have recourse 
to suitable treatment, the local death having stealthily extended beyond the 
bounds of arrestment, when even the most energetic measures will in all proba- 
bility prove unavailing. 

"There can be no doubt as to the propriety of at once attacking locally the 
local manifestation of the disease, whatever its real essence may be, for here the 
sooner we destroy, the less will be the ultimate destruction ; and although it 
may, to those especially, who may not have witnessed cases of the kind, seem a 
cruel and uncalled-for procedure to cauterize "the apparently slightly-affected 
cheek of a perhaps not unhealthy-looking child — a child whose appetite may be 
little afiected, or whose pulse or expression may not indicate any immediate 
danger, although to others it may seem harsh, and may be unpleasant to our- 
selves, still the duty ought to be in all suitable cases timeously and properly 
done. 

"Although it is now impossible to say what would have been the result of 
early and thorough cauterization, in the fatal case which recently occurred in 
the Children's Hospital (and of which a correctly coloured wax model is now 
exhibited), there can be no doubt that the serious nature of the case had been 
overlooked until the disease had made considerable progress, when the local 
applications first used were neither sufficiently corrective to change, nor suffi- 
ciently corrosive to destroy, the sloughy actiou in the parts involved. 

" I believe that the issue would not have been different had the hydrochloric 
or other acid been applied on admission ; and my reason for first applying the 
^erchloride of iron, and also Condy's solution, was to see if either of these local 
remedies would have any beneficial effect along with the general tonic treatment 
which was at the same time studiously adopted. The mortification having in 
this case involved the entire thickness of the cheek, there was little hope of 
checking it after the admission of the patient. 

"Be that as it may, from what I have seen and known of cancrum oris, I would 
rather, in any future case, be inclined to overdo than underdo — rather run the 
risk of disfiguring too much than of destroying too little ; for cauterization, if 
Uot effectual, is worse than letting alone ; and now that we can avail ourselves 
of the aid of chloroform, there need be no hesitation in at once setting about 
this to my mind essential matter. Without chloroform, it is a difficult as well as 
a painful task to apply caustic or other substance efficiently to the interior of a 
child's mouth, and especially 50 in the diseased condition we are now consider- 
ipg ; for here the difficulty of seeing the internal sloughy surface to which the 
escharotic ought to be applied, is very much increased by the peculiar tense and 
tumid state of the affected cheek, which, even under chloroform, materially inter- 
feres with our getting at the exact part which we may desire to cauterize. In 
fact, this swollen an,d tense condition of the affected cheek, although an early 
and valuable external characteristic of the condition of the internal surface, is 
generally the cause of our not diagnosing and treating cases at the proper time, 
that is, before the sloughing process has extended outwards beyond the mucous 
or inner texture of the cheek, in which the disease usually commences, and to 
which, therefore, our local remedies ought to be early applied. 

"With chloroform this difficulty is very much overcome, as was found in one 



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Medical Pathology and Therapeutics. 



229 



of the cases I have cited, and in which there can be little doubt as to the success 
of the local treatment which was had recourse to. The arrest of the disease 
was very apparent in that case, and the advantage o'f chloroform was undoubted, 
as it enabled me not only to displace the swollen cheek, but to expose its affected 
surface and the adjoining gums, and thereby allowed me to see what required to 
be done, and thus greatly facilitated the doing of it. 

''In the case referred to, I used nitric acid, and, as stated in the report, found 
one application sufficient. The cheek was forcibly turned out, the tongue and 
adjoining parts were protected from contact with the acid, which, in the absence 
of a glass rod, was applied by means of a test-tube. Some apply it by means of 
lint or tow attached to a probe or quill, but the glass rod, or, better still, a glass 
brush (such as I' now exhibit), answers every purpose required. 

"In every case care must be taken to see that under the yellow slough or 
eschar left by the first cauterization, there do not lurk unaffected sloughy por- 
tions ; if so, the acid should be reapplied on the following day, and the mouth 
should be occasionally syringed with solution of chloride of lime, in order to 
remove the putrid discharges and get rid of the gangrenous emanations which, 
so long as the dead and dying tissues are left exposed or unaltered, must neces- 
sarily prove highly deleterious, if they be not the more immediate and direct 
cause of death. The danger arising from the presence of decomposing matter 
cannot be too constantly borne in mind in dealing with cases of true cancrum 
oris ; for, whatever be the exact pathological nature of the structural change — 
whether simply the result of an inflammatory exudation into tissues unusually 
prone to serous infiltration and capillary death, or consequent on contamination 
of the circulating fluids (a general blood-poisoned condition leading to a special 
disorganization in the affected parts), there is to my mind no great difiiculty in 
accounting for the marked fatality attending the disease when allowed an un- 
checked course ; indeed its fatality seems explicable enough, without looking for 
any cause of death beyond or apart from the mouth itself, for there we find a 
mass of gangrene which, having lost the inherent power as well as the inherent 
character of living tissue, is not only incapable of self-regeneration, but is most 
unlikely to be spontaneously separated or removed by absorption. It is, I con- 
sider, by no means improbable that death ensues in such cases not so much from 
any previous diseased condition or contamination of the blood, as from the con- 
tinued and unavoidable inhalation of the poisonous exhalations arising from 
the gangrenous degeneration within the mouth, which must necessarily be a 
much more active, as it is doubtless a much more direct medium of blood-con- 
tamination than mere local absorption, which latter agency, together with the 
actual deglutition of the foul discharges from the affected structures, materially 
tends to destroy life. 

"It appears to me, that children dying from unchecked cancrum oris are in a 
great measure poisoned by the inhalation of the deleterious gases arising from 
their own oral textures in a more or less complete state of putrefaction ; and 
that this view of the cause of the extreme fatality of the disease not only explains 
the immediate cause of death, but points to the necessity for adopting the line 
of treatment I have so strongly recommended, in order to prevent the air inhaled 
from being thus directly poisoned. 

"It may, I think, be safely affirmed, that so long as simple ulcerative action 
exists, this mode of death need not be feared ; but that, whenever gangrene /rom 
degeneration takes place within the mouth, fatal consequences may accrue ; for 
if foul air, under any circumstances, be poisonous — if the emanations given off 
from putrid animal matters be deleterious in proportion to the degree of con- 
centration in which they are inhaled, what I have now advanced must, I appre- 
hend, be correct. This view of the pathology of the disease, moreover, accounts 
not only for the efficiency of such substances as chlorate of potass in the milder 
and more curable form of stomatitis, but justifies us in preferring active and 
well-timed local, to less powerful or merely general treatment in gangrenous 
stomatitis, in which the air within the mouth is so polluted as to render the 
atmosphere, not only immediately around the unfortunate patient but throughout 
the entire apartment, in the highest degree offensive. 

"If this be true (and those who have ever visited a well-marked case of can- 



230 



Progress of the Medical Sciences. 



[July 



crum oris can voucli for tlie fact), the conclusion is obvious, and may be thus 
shortly put. If it be dangerous to allow a foul drain or open cesspool to pollute 
the air which enters the lungs, the sooner the nuisance is either removed or 
covered over the better. And this is exactly what cauterization accomplishes 
in the case of cancrum oris ; for, if it have not the effect of immediately disinte- 
grating and removing the entire putrid mass, it either so far changes its charac- 
ter, or, at least, for the time being so covers or crusts over the gangrenous 
degeneration, as to check or altogether prevent the farther escape of those 
offensive and most deleterious exhalations, which would otherwise freely mix 
with, and therebv render poisonous, what may be emphatically called the 'breath 
of life.'"— ^;cZ. Med.-Journ., April, 1862. 

25. Patliology and Treatment of Jaundice. — Dr. George Harley read a 
paper on this subject (May 13, 1862) before the Eoyal Medical and Chirurgical 
Society. 

It is universally admitted that the facility of the diagnosis of jaundice is only 
equalled by the obscurity of its pathology and the uncertainty of its treatment. 
In this communication, therefore, the author set about unravelling the nature 
of the various morbid conditions which give rise to it; and pointed out how, 
notwithstanding the seeming discord, they could all appropriately come under 
the two common heads of "jaundice from suppression of the biliary function." 
and "jaundice from the reabsorption of the secreted but retained bile." More- 
over, I)r. Harley showed that the pathology of jaundice resulting from suppres- 
sion is totally different from that arising from obstruction : and, consequently, 
that a line of treatment which would be appropriate and beneficial in the one 
form, would be detrimental, if not actually hazardous, in the other. Fortunately, 
however, the author pointed out a new method of distinguishing the two forms 
of the disease when all the ordinary means of symptomatic and physical diagnosis 
prove unavailing. The method consists in analyzing the urine, which, he finds, 
contains different morbid products according to the particular form of the dis- 
ease. Thus, for example, in jaundice from suppression the urine contains only 
those biliary ingredients which exist preformed in the blood. In jaundice from 
obstruction, on the other hand, the urine contains, in addition to these, the 
materials generated in the liver itself, and which have been reabsorbed into the 
circulation from the distended gall-bladder and ducts. A simple mode of distin- 
guishing the two conditions is, to add to about two drachms of urine half a 
drachm of strong sulphuric acid, and a fragment of loaf sugar the size of a pea. 
If at the line of contact of the two liquids a scarlet or purple colour is produced, 
it proves that the acids of the bile are present, and the case may consequently 
be put down as one of jaundice from obstruction. On the other hand, if no 
bile-acid reaction, but merely a browning of the sugar, be observed, the case is 
in all probability one of suppression. Dr. Harley pointed out, however, that 
care must be taken not to confound the two cases; as jaundice from obstruc- 
tion, especially the severe form, often merges into jaundice from suppression. 
The author also confirmed Frerich's statement regarding the presence of tyrosine 
and leucine in the urine of acute atrophy of the liver ; and further stated that 
he had also found these substances in the urine of chronic atrophy, so that their 
presence might aid in the diagnosis of the latter as well as of the former condi- 
tion of the hepatic organ. Several cases were cited illustrating the value of the 
different methods of diagnosis; and the author concluded by pointing out the 
class of cases in which mercury and other remedies were likely to be beneficial, 
and where they were likely to do injury. He specially recommended the em- 
ployment of benzoic acid in jaundice from suppression, and inspissated bile in 
that arising from obstruction, in which latter class the patient frequently dies 
from slow starvation, in consequence of the absence of bile in the digestive 
process causing imperfect assimilation of the food to take place. Dr. Harley 
also called special attention to the fact that bile, as now employed, more, fre- 
quently does harm than good ; for, when given along with the food, instead of 
aiding the digestive process, it actually retards it by interfering with the action 
of the gastric juice. If, on the other hand, bile be administered, as the author 
proposes, at the end of stomachal digestion, it acts (as in the healthy organism) 



1862.] 



Medical Pathology and Therapeutics. 



231 



on the chyme, and renders it fit for absorption. In order still further to insure 
this desirable object, Dr. Harley has had bile specially prepared and put up 
into capsules, which are not readily acted on by the gastric juice, but which, on 
being dissolved in the duodenum, allow the bile to come in contact with the food 
at the proper moment, and thereby enable the physician to imitate nature, and 
supply an important element to the system. The communication was well illus- 
trated with preparations and drawings. — Jled. Times and Gaz., June 7, 1862. 

26. Treatment of Dysentery. — In the acute form, and in the inflammatory 
stage, bloodletting, general and local, remarks Dr. S.maet [ClimatoL, etc., of 
Hong-Kong), and the warm bath, are always the earliest means to be used. 
Everything should be done with a view to diminish the inflammatory impulse, to 
keep the muscular coat of the bowel at rest, and to determine to the surface, as 
long as the excretion is of mucus and blood, and, d fortiori, when it is of serum, 
blood-corpuscles, and lymph-flakes. Purgatives of any kind, especially calomel, 
which excites the discharge of bile into an already inflamed canal, can only have 
an injurious eflFect. Astringents, which tend to check the exosmotic action by 
which the inflamed capillaries are relieving themselves, are pernicious. Ipeca- 
cuan possesses of all known remedies the most relaxant power on mucous tissues, 
causing a kind of internal diaphoresis and checking the peristaltic action of the 
lower intestines, by nauseating and thus reversing that of the upper part of the 
canal, and by producing vomiting, by which the secretions poured in by the 
lower and the upper mucous glands are prevented passing through the large 
intestine. Opium, which calms the nervous excitement, deadens the pain and 
assists in moderating peristaltic action, is also invaluable. In this consists the 
merit of the treatment proposed by Surgeon Docker, of the Eoyal army, from 
his practice in the Mauritius, of giving large doses of ipecacuan combined with 
laudanum. In my practice I have found the most satisfactory results from this 
treatment, preceded by venesection and the warm bath. The recumbent jDosture 
and epithems to the abdomen, with absolute diet of rice or barley water, are 
most important adjuncts. When the tenesmus is lessened, and the passage of 
bile and feces shows the cessation of ileo-colic obstruction, a laxative of castor 
oil, with laudanum or oil of turpentine, will be useful ; but after the second or 
third fecal stool, further action should be checked by opiates, administered by 
mouth, and in starch injection. As the symptoms moderate, the doses of ipeca- 
cuan are to be gradually diminished ; and, at last, when bloody mucus has giyen 
way to opacjue mucoid or muco-purulent discharges, some mild alterative, such 
as hydrar. cum creta, may be combined with the ipecacuanha. 

This mode of treatment, as far as I have seen, cures more in the first stage, 
by resolution, than any other; but, even with it, absolute success must not be 
expected, as some cases will run to a fatal termination in the first stage, and 
others will progress to the second stage, with dense infiltration of the submucous 
tissue. This is known to have occurred when the pyrexia having abated, there 
remains a minor degree of tenesmus and tormina, with tenderness. <iccompanied 
by an altered state of the evacuations. Then, the modified treatment, by ipeca- 
cuan with alteratives, epispastics, and sometimes leeching over the tender points, 
and anodyne enemata, especially about midnight, is still most to be relied on. 
If breach of mucous surface has occurred, as indicated by renewal of mucus 
streaked with blood, and pultaceous or curded matter in the stools, the use of 
the vegetable tonics and astringents, as cinchona, quinia, and calomba, with 
occasional alterative laxatives, is to be had recourse to, and a broth, farinaceous 
diet, with a little port wine, may be allowed. If the symptoms be obstinate, the 
alternation of the mineral astringents, especially if there be passive hemorrhage, 
will be advisable. The terebinthinates will often be of great service in this stage ; 
but should the urinary bladder partake of irritability they must be suspended. 
Unless the patient can be brought to feel that all injudicious ingesta are most 
detrimental to the diseased alimentary canal, any mode of treatment will be very 
unsatisfactory. — Trans. Epidemiolog. Soc. of London, May, 1861. 

27. Suhnitrate of Bismuth in Diarrhoea and Chronic Dysentery. — Subnitrate 
of bismuth is considered in the present day one of the best remedies in cases of 



232 Progress or the Medical Sciences. [July 

diarrlioea, and is employed with great advantage in the treatment of chronic dysen- 
tery. Under its influence the ulcerations cicatrize, the fetid gases are destroyed, 
and the excrements become black and lose their putrid character. But as the 
medicine requires to be taken in large doses, in order that it may exert a bene- 
licial influence, some patients soon become disgusted with it, in spite of its in- 
sipidity. Dr. Gaubert announces that he has found cream a very convenient 
recipient for its administration, especially in the case of young lymphatic subjects, 
who generally require tonics, and in whom the sensibility is often exaggerated. 
This preparation, due to Dr. Quesneville, has the advantage of presenting the 
subnitrate of bismuth in the form of a thick cream, which, on the addition of 
water, forms a milky fluid, without granular residue ; and it will be readily com- 
prehended that this state of minute division is highly favourable to its diffusion 
throughout the digestive canal, and consequently to the rapid obtaining of its 
therapeutic effects; so that smaller doses than ordinary are sufficient. — Gazette 
Hebdom., 28 Feb. 1862, from Gaz. M6d. de VAlgerie, 25 Dec. 1861. 

28. Saccharine Treatment of Diabetes Mellitus. By John Hughes, M. D. — 
The saccharine plan of treating diabetes originated, I believe, in France, and so 
far back as 1845. Bouchardat gave saccharine fruits in diabetes, and bread 
made from gluten. Andral and Fiorry tried a similar treatment, with some 
success. And the practice has been recently adopted in England, by Dr. Budd, 
of Bristol, who has published some cases (two, I think) in which he says the 
most marked amendment followed the use of sugar. Others have also recorded 
cases ; but they do not exhibit so favourable a result as those of Dr. Budd. It 
would appear, however, that some practitioners who tried this plan have found 
it beneficial. Their patients grew fat upon it ; and even this effect, in a disease 
where wasting is so prominent a symptom, is a very desirable result. They say, 
besides, that the practice is not an irrational one ; for Bernard has shown that 
sugar taken into the stomach, in its passage through the liver, is converted into 
an emulsive substance, which tends to fatten patients ; and he has also proved 
experimentally, and Andral and others practically, that sugar is secreted and 
found in the circulation in diabetes, whether the individual be fed upon nitro- 
genous ,or amylaceous substances : consequently our old-established plan of 
dietetics in this disease, with all its restrictions, is useless. 

Dr. Budd, one of its earliest advocates in England, says he gives sugar in 
diabetes on the principle of supplying to the system the particular element 
which is running to waste, and the loss of which appears to be the principal 
cause of the damage sustained by the constitution as the disease advances. On 
all these grounds, then, it has been considered that the saccharine treatment of 
diabetes is worthy of a trial. 

Amongst the many theories propounded concerning this intractable disease, 
modern researches incline to the opinion that the liver is the organ in fault — an 
idea long since entertained by Dr. Front. Experiments by Bernard and Favey 
tend to show that there is always present in the liver, located in the hepatic 
cells in considerable abundance, a substance which one calls the "glucogenic 
matter" of the liver, the other "hepatine;" that this substance is, with great 
facility, by a process allied to fermentation, converted into sugar ; but that it 
seems to have the power, whilst located in the tissues of the living and healthy 
liver, to resist the transformation. In certain unnatural conditions, however, as 
well as after death, this power is at an end, and the blood becomes surcharged 
with saccharine principle. 

If this be true, it would appear that the diabetic condition depends upon some 
functional derangement of the liver, which converts alimentary substances into 
this glucogenic matter in greater abundance than natural, and allows it to mix 
with the blood in large quantity, when it immediately becomes converted into 
sugar, and as such passes off with the urine. 

I am not sure, even assuming all this to be correct, whether we are in a better 
position to decide upon the exact nature of this disease. Frobably, however, it 
is to physiology we shall have to look, in the end, for a solution of this difficult 
question ; for pathology is strangely barren of results in this disease ; so much 
so that it is doubtful whether the presence of sugar in the system either necessarily 



1862.] 



Medical Pathology and Therapeutics. 



233 



depends upon, or produces, visible organic lesion of any particular organ. When 
organic diseases do exist, they are looked upon as merely concurrent affections. 

However, it is not my intention to discuss the nature of diabetes mellitus : I 
merely wish to give a brief account of how this saccharine plan of treatment 
turned out in my hands, after a trial of more than four months. 

Four cases of diabetes mellitus came under my care in hospital, almost simul- 
taneously. 

The first was a man named Thomas Eyan, aged 37, who had been diabetic for 
thirteen months before admission, and had been under treatment for his disease 
during the greater part of that time. On admission he was voiding, daily, eight 
pints of urine, specific gravity 1049, and containing 22 grains of sugar in each 
ounce. He complained of great thirst, languor, and debility; the skin and mu- 
cous membrane were dry; the bowels confined; and all the usual symptoms of 
diabetes were present. 

I treated this man with Dover's powder and the vapour bath, for a fortnight, 
when he left the hospital relieved in respect to the condition of the skin and 
mucous membrane ; his thirst was abated, and the skin was somewhat moist ; 
the quantity of urine varied with the amount of fluid drank, but its condition 
was unaltered. He thought he was growing weak, and wished to go home. He 
told me his father had a complaint similar to his own. 

This man returned on the 18th of January, and was then voiding ten pints of 
urine daily, of a specific gravity 1041, 24 grains of sugar in each ounce. He 
said he drank a large quantity of beer, one day, at home, and was not as well 
since. I now determined to put him on the saccharine treatment, and ordered 
him six ounces of barley sugar daily; diet of fresh meat, with green vegetables 
and bread ; also a moderate quantity of lime-water and milk. He continued this 
plan steadily for three weeks ; and at the end of that period his condition was, 
to a certain extent, improved. The quantity of urine passed was seven pints, 
the specific gravity 1041 : each ounce contained 24 grains of sugar ; and he 
gained two pounds in weight. The skin was somewhat moist, thirst abated. 
He was again anxious to return home, and left the hospital. 

The second case was a man, aged 40 ; but as he was not in the hospital more 
than a week, and was treated with sudorifics (Dover's powder) alone, and almost 
an exclusively animal diet — I will only refer to his case. In fact, he would not 
submit to the abstinence from fluids, and the variety of food which I enjoined. 
He left without any apparent change. There was one fact connected with him 
of interest — he told us his father had the same ailment he was labouring under, 
and died of it. 

The next patient was a man aged 32 (John O'Neill), who suffered from the 
complaint for 18 months before admission. On the 3d January he was voiding 
15 pints of urine, of a specific gravity 1043, 18 grains of sugar to the ounce. 
He was very thin, and had all the symptoms of diabetes in an aggravated form. 
He was treated with sugar and a mixed diet, like the former patient ; and at the 
end of six weeks his urine was reduced in quantity to six pints — the specific 
gravity remaining the same. All the other symptoms were greatly relieved, and 
he felt himself much better and stronger ; in fact so well that he was anxious to 
go and resume his former employment (that of a shopman). Yet. on weighing 
him, we found he had lost four pounds in weight since his admission, and his 
urine contained 22 grains of sugar to the ounce. We heard that he since died 
of phthisis. 

The last and most interesting case is that of Henry ]S['Xee. He was a mar- 
ried man, 30 years of age ; tall, well-proportioned, and of a very athletic frame. 
He was always temperate; had no hereditary predisposition to the disease, and 
attributes his illness to profuse perspirations and alternate chills while working 
as a railway labourer. Five years ago, when employed in England, he first 
noticed his disease, and was treated for it at the Manchester Infirmary. After 
four months' stay in that institution, he left at his own request, relieved suflB- 
ciently to resume his work, at which he continued for 11 months before admis- 
sion. At that time he noticed the aggravation of his disorder, which set in 
with great thirst, increased flow of urine, general weakness, and rapid loss of 
flesh. 



234 



Progress of the Medical Sciences. [July 



On admission, all those symptoms had attained a great intensity. He said he 
was only the skeleton of his former self; for, when in health, he weighed more 
than 14 stone, and now he did not reach 12 ; which surprised him, when he could 
eat so much — four times his ordinary quantity — and he did not feel sick, only 
very weak. He was voiding 10 quarts of urine in 24 hours, of specific gravity 
1049, and was obliged to empty the bladder every hour. He drinks about the 
same quantity of fluids within the same time. His urine has an acid reaction, is 
free from albumen, and each ounce contains 24 grains of sugar. As an evidence 
of his broken-down health we found a large, chronic, indolent ulcer over the right 
external ankle. 

I was determined to give the saccharine treatment an uncomplicated trial in 
this case ; and, after an aperient, I put the patient on six ounces of sugar, daily, 
together with four ounces of treacle ; bread, meat, and green vegetables for diet ; 
lime-water and milk for drink — with an injection to limit the amount as much as 
possible. 

At the end of a month he was somewhat improved. He had gained two 
pounds in weight; his thirst and appetite were diminished; the quantity of urine 
passed in 24 hours was reduced from 10 to 7 quarts ; the specific gravity ranged 
from 1043 to 1045 — 26 grains of sugar to the ounce. 

During the next month he had two attacks of sudden and violent sickness of 
stomach, accompanied with constant vomiting and cramps in the abdomen and 
legs. He complained, for a few days, of great nausea, and felt as if saturated 
with sugar ; everything, he said, tasted sweet. He was, at the same time, weak. 
The urine was of a specific gravity of 1044 — not lessened in quantity. The ulcer 
of leg was healed. The sugar treatment was discontinued. 

After the lapse of a few days the sugar was again resumed ; and his condition, 
at the end of another month, was as follows : His weight, 12 stone ll-lbs. ; con- 
sequently he had gained nine pounds since last report. His urine is reduced to 
three quarts in 24 hours ; and he is not disturbed more than once or twice to 
pass it during the night. His skin is moist ; his bowels are regular ; he has 
gained strength, for he is able to work at the force-pump of the hospital for an 
hour without resting. The specific gravity of the urine is 1035-9, but it contains 
a greater amount of sugar than before. According to Garrod's glucometer each 
ounce contains 40 grains of sugar. His appetite and thirst have decreased; the 
ulcer of the leg has broken out again. 

After four months' stay, he left the hospital in the month of May, and obtained 
employment as a porter, which obliged him to carry considerable weights ; he 
remained at this work for six months, during which time I saw him occasionally ; 
but at the end of that period he was completely prostrate, and sought relief in 
another hospital. As the sequel of his case has been published, I will add some 
extracts from the report : — ■ 

He was admitted into Dun's Hospital, under the care of Professor Law, in 
the month of January, and was then voiding 16 pints of urine in 24 hours — spe- 
cific gravity 1042. On the 10th of February the quantity of urine was 12 pints 
— specific gravity 1035-9, and contained 8.750 grains of sugar, or about 45^ 
grains to an ounce. On the 8th of March the quantity of sugar was 39 grains 
to the ounce, the amount voided being the same. On the 20th March the quan- 
tity of sugar declined to 34 grains ; and on the 8th May the urine was reduced 
to 10 pints ; there were 38 grains of sugar in each ounce. 

He left the hospital in July; but was again readmitted late in October, in an 
advanced stage of phthisis ; and on the 10th November the post-mortem exami- 
nation showed extensive tubercular disease in both lungs. "Both kidneys were 
very large ; one weighed 12|- ounces, the other 11. Both were much congested, 
but exhibited no trace of disease or deviation from their normal structure. The 
liver was perfectly normal in size and appearance : and, on examination, did not 
contain a trace of sugar. It was, in fact, to the eye and to chemical analysis a 
specimen of a healthy liver." 

It will be seen from these cases in which the saccharine treatment has had a 
pretty fair trial that, to say the least, it produced no permanent improvement. 
'J'he specific gravity of the urine was not altered, and in each instance its sac- 
charine quality was aggravated. Tis true the amount of urine voided within a 



1862.] Medical Pathology and Therapeutics. 



235 



given period was considerably diminished ; but I think that result is very much 
within the control of the patient, exclusive of medieine. I mean, of course, if 
he checks his desire for fluids. The gain in weight and the increased strength 
may be more justly attributed to other causes than to the amount of sugar taken ; 
and I am quite satisfied, so far as my observation enables me to judge, that the 
saccharine treatment of diabetes is not entitled to the credit which its advocates 
claim for it. All that can be said for it is, that it is vastly agreeable to patients, 
and is not positively injurious, as one might ci 'priori be inclined to suppose. — 
Dublin Quarterly Journ. Med. Sc., May, 1862. 

29. Chorea treated hy Sulphate of Aniline. — Dr. Morell Mackenzie reports 
{Medical Times and G^aze^^e, March 8, 1862) five cases of chorea treated in the 
London Hospital, under the care of Dr. Fraser, by the sulphate of aniline, and 
in all it failed to relieve the symptoms. 

Dr. Thos. Skinner reports in the same journal, for March 15th, another case 
of failure of the sulphate of aniline to relieve chorea. 

30. Individual Remedies in Epilepsy. — Dr. Anstie read a paper before the 
Medical Society of London (March 24, 1862), in which he gave the results of 
his own experience in the use of certain remedies in epilepsy. These were of 
two kinds — tonics and sedatives : of the former he had made careful experiments 
with cod-liver oil, quinine, and phosphorus, and also to a certain extent with 
iron ; but of the effects of this last remedy he had not kept a tabulated record. 
Ood-liver oil was employed alone in twelve cases among the out-patients of 
Westminster Hospital and Chelsea Dispensary : the disease was in every instance 
of the simple or " idiopathic" kind ; and the following results were obtained: 
Three complete failures (patients aged 14, 26, and 32, respectively ; in all of them 
the disease was of long standing) ; one case in which the patient, a man, aged 44, 
derived no relief as far as regarded the fits, but his mental condition was im- 
proved ; two cases (aged 10 and 12) which were improved, the fits being lessened 
in frequency, but the patients disappeared from the author's supervision while 
still by no means cured ; and, finally, six cases, all still under observation, in 
which the fits have ceased entirely, and, so far as can be seen, the disease has 
been cured. Out of these six cases, two were sufficiently grave to put the efficacy 
of the remedy to a severe test ; one of them was that of a girl, aged 17, epileptic 
from infancy, and in whom the fits had for some time past been happening two 
or three times every day ; the effect upon the facial aspect and upon the intel- 
ligence of the patient had been very serious. Cod-liver oil was employed per- 
sistently for three months with the effect of inducing an entire cessation of the 
fits, and a most marked improvement in the intellectual and sensorial functions. 
The other case was that of a boy, aged 13, in whom the disease, which was here- 
ditary, had come on six months previously. The fits were not very frequent, but 
were very severe ; the memory was a good deal affected, and the shape of the 
head and the aspect of the face were far from encouraging. Nevertheless, a 
complete cessation of the fits soon followed the use of cod-liver oil. The remedy 
was persisted in for six months on account of occasional threatening symptoms ; 
but even these have quite disappeared. The mental condition is much improved, 
and the boy may be pronounced cured, as far as we dare use that term at all. 
Quinine had been used singly in six cases : two of them had entirely resisted its 
influence (both these patients were women), a third had been very much bene- 
fited, the fits being much reduced in frequency, and an unpleasant numbness in 
the leg having disappeared. In the other three the improvement apparently 
amounted to cure. One of these cases, in which a very marked and peculiar 
aura was present, was minutely analyzed, and the influence of the quinine in 
stopping the aura, and altogether averting the paroxysms, was plainly shown. 
DoulDtless local measures might have done much in this case, but they were 
intentionally and successfully dispensed with. All the cases treated by the 
author with quinine had been distinguished by the presence of some persistent 
local pain or numbness. Phosphorus had been tried by the author in only two 
cases of epilepsy, at the suggestion of his friend and colleague. Dr. Radcliffe, 
who has recommended its use in his book, as also that of cod-liver oil. The cases 



236 



Progress or the Medical Sciences. 



were inveterate ones, in wHcli cod-liver oil had failed to produce any effect. The 
phosphorus was given in doses of five to ten drops of the phosphoretted oil of 
the Prussian Pharmacopoeia, three times a day. The fits were not lessened in 
frequency, but the general condition of the patients was much improved, and 
the miserable sense of nervous depression greatly relieved. Phosphorus ought 
to be extensively tried in epilepsy and in other nervous affections. With regard 
to iron, the author not having kept tabulated reports of its effects, was only able 
to confirm, in a general way, the popular belief in its great utility. He was in 
the habit of limiting its employment to cases distinguished by anaemia ; and he 
related one or two instances of its usefulness when given in such cases. The 
author remarked that all these four tonics, cod-liver oil, steel, cjuinine, and phos- 
phorus, were distinguished by the fact that they acted as foods, either to the 
nervous system, or the blood that nourishes that system. Looking at the success 
obtained by himself, and by other observers of larger experience, and also to the 
fact that the whole group of chronic convulsive diseases, of which epilepsy may 
be said to form the centre, are curable, if at all so, in nine cases out of ten by a 
nutrient-tonic regimen — the author urged that there was the greatest reason for 
extended experiments with remedies of this class, experiments which should be 
patiently persisted in for months together, no other medicines being used, except 
aperients when necessary. The sedatives of which the author had made par- 
ticular trial were opium, hyoscyamus, belladonna, and sulphate of aniline. With 
regard to belladonna, he must state that he had not thought it right to push it 
to the extent of producing wide dilatation of the pupil for a long time together. 
He had administered it in doses of one-sixth grain of the extract twice or three 
times a day, a quantity which is usually sufficient to produce the minor effects 
of the drug, namely, relief of neuralgic pain, and resolution of muscular spasms ; 
and in these doses the results were very equivocal, and by no means encouraging. 
With regard to the other three sedatives, the author regarded it as proved by 
his own experience, that in a considerable number of instances they possess the 
power of delaying the fit, or mitigating its severity; and for this purpose he was 
at present inclined to give the preference to the sulphate of aniline. This remedy 
he had tried repeatedly upon six epileptic patients, and also in many other cases 
of chronic convulsive disease. It was a most serious mistake to administer sul- 
phate of aniline, or indeed any other sedative, in large doses, with a view to arrest 
or diminish convulsive muscular action. In the only two cases of epilepsy in 
which the author had pushed it to the extent of large doses, on account of the 
failure of small quantities, a serious aggravation of the fits occurred. In doses 
of one grain three times a day, with an additional grain to be taken immediately 
on the occurrence of anj prodroinata of a fit, sulphate of aniline seemed to ma- 
terially benefit four patients to the extent of delaying or mitigating the paroxysm, 
and in three separate instances the fit seemed to have been altogether averted 
for a considerable time. 

In conclusion, the author desired to state his conviction that future experi- 
ments with sedatives should be limited to the use of small doses only, and that 
they should be employed chiefly in the slighter cases of epilepsy which are not 
of long standing, or in those in which tonics and nutrition had already done much, 
but had not quite effected a cure. In short, wherever we could reasonably hope 
to effect good by the mere fact of breaking through the vicious habit, so to speak, 
of convulsion ; then we might well try experiments with sedatives, and the results 
obtained by each observer should be numerically noted, and published. — Med. 
Times and Gaz., April 5, 1862. 

31. Statistical Inquiry into the Prevalence of Numerous Conditions affecting 
the Constitution in one thousand Phthisical Patients when in Health. — Dr. 
Edward Smith read a paper under this title to the Royal Medical and Chirur- 
gical Society (March 25, 1862). After some preliminary remarks, the author 
described the method which was pursued in the inquiry, and offered an estima- 
tion of the trustworthiness and value of the answers which he had recorded. 
There were 600 male and 400 female cases, all attending at the Hospital for 
Consumption, and in the stages of marked consolidation or destruction of the 
lungs. He then quoted the scheme of inquiry proposed to each patient, con- 



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Medical Pathology and Therapeutics. 



237 



sisting of 138 queries, aud the following is a summary of the facts obtained : 
The average age of the patients was 28.8 years. 30 .per cent, had been born in 
London, 36 per cent, had lived chiefly in London, and 53 per cent, had lived in 
London during the preceding three years. 8.8 per cent, could not read nor 
write, and only 14.3 per cent, had been insufficiently nourished. 1. Parerital 
conditions. — 54 per cent, had lost the father ; 46 per cent, the mother ; and 28 
per cent, had lost both parents. In 25 per cent, only were both parents living. 
The average age of the parents at death was 50.8 years, with an increased dura- 
tion of 4.7 years on the part of the fathers. The most frequent age at death 
was 35 to 55 years ; whilst only 11 per cent, died under the age of 35, and some 
lived upwards of 95 years. 18 per cent, had experienced feeble health before 
the birth of the patient, and 34 per cent, throughout life. In 22.7 per cent, one 
or both parents had led unsteady lives. 21.1 per cent, of the parents had died 
of consumption ; whilst in 2.8 per cent, the grandparents, 23.3 per cent, the 
brothers or sisters, and 9.1 per cent, the uncles or aunts, had died of the same 
disease. They had suffered from rheumatism in 22 per cent., from asthma in 

9.4 per cent., from liver disease and gout in 9 and 7.2 per cent., and from fevers, 
ague, insanity, and diabetes in 4 and 5 per cent. Presumed scrofulous affections 
were extremely rare. In only six cases was there consanguinity of the parents. 
The age of the parents at the birth of the patient was in half of the cases from 
25 years to 35 years ; and in only 2 per cent, was it less than 20 years. The 
number of the children was very large, viz., an average of 7.5 to a family, and 
in some families there were 23 children. The patient was the first child in 20 
per cent. ; and the first, second, or third child in half of all the cases. 40 per 
cent, of the parents' children had died. 2. Personal conditions. — In only 23 per 
cent, were the patients under 20, and a few were 60 years of age. 24 per cent, 
had been feeble at birth, whilst 22 per cent, had suffered from feeble general 
health and 17 per cent, from generally defective appetite. In 12.6 per cent, the 
lungs had been always delicate; 2.5 percent, had been dry nursed; 25.4 per 
cent, had perspired with unusual freedom ; 25 per cent, had never worn flannel 
next the skin; and 55 per cent, had suffered from coldness of the extremities. 
72.5 per cent, had an excitable temperament ; 62.1 per cent, had medium brown, 
or light-coloured hair ; 74 per cent, had gray or blue eyes ; 60 per cent, had 
florid complexions ; and 46.7 per cent, had a fleshy habit. 16, 65.4, 60, and 41 
per cent, had not had measles, scarlet fever, smallpox, and whooping-cough in 
their order ; and the frequency of any long-continued ill-efiects from these dis- 
eases was insignificant. 12.8 per cent, had suffered from enlarged glands, and 

4.5 per cent, from long-continued affections of the eyes ; but otherwise the evi- 
dences of scrofulous disease scarcely existed ; 16.7 per cent, had suffered from 
inflammation of the lungs, and 14.8 per cent, from rheumatism ; whilst typhus 
fever and frequent diarrhoea had occurred in 8 per cent., ague in 5.6 per cent., 
and Uver disease in 4.3 per cent, of the cases. The menstrual epoch was at the 
age of 14 and 15 in 36.4 per cent., and in 11 per cent, only was it before the age 
of 13; 40 per cent, had complained of general irregularity, and in 29 per cent, 
the quantity was insufficient. Leucorrhoea was considerable in 42.2 per cent. 
43.5 per cent, were married ; and of these, 13 per cent, were childless at the 
period of inquiry. Their average age at the birth of their first child was from 
20 to 25 years, and in only 9 per cent, were they under 20 years. The number 
of children per family was 1 and 2 in 44 per cent., and 1, 2, and 3 in 55 per cent, 
(the patients' average age was 28.8 years). 38 per cent, of the children had 
died, and in 43 per cent, the general s^tate of the health of the children was bad. 
Abortions had occurred in 46.2 per cent, of the child-bearing married women, 
aud some had suffered eight abortions. 11.6 per cent, of the males had com- 
mitted sexual abuse ; 18.2 per cent, had been addicted to masturbation, and 22 
per cent, had suffered from involuntary emissions. 16 per cent, had syphilis, 
and 38.5 per cent, gonorrhoea; one on several occasions. 29.6 per cent, had led 
a bad life at some period, 24.5 per cent, had drunk to excess, and 48 per cent, 
had smoked tobacco ; 19.3 per cent, of both sexes had submitted to late hours, 
and 22.2 per cent, had suffered much anxiety. In 70 per cent, there was some 
complaint as to the injurious influence of their occupations, and of those causes, 
exposure, long hours, close and hot rooms, bending postures, and dust or fumes, 



238 



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[July 



were complained of in 32.1, 28.6, 24.4, 20, and 15.8 per cent, in their order. 9 
per cent, had taken mercury largely, and 54.4 per cent, had been bled at the 
arm from 1 to 12 times. The author then considered some of the most important 
truths which the inquiry had evoked, and particularly the questions connected 
with hereditary transmission ; the especial liability of the female sex to many of 
the conditions pointed out, and the state of the system ; the diseases and the 
effects of the immoralities of life upon the patients. With regard to the greater 
liability of females over males, it was shown, in reference to parents, that more 
mothers than fathers who had children early, had feeble general health, and had 
died early. More female than male patients had mothers who died early; had 
most relatives who had died of phthisis ; had parents with one child only ; had 
experienced feeble health and defective appetite throughout life ; had had deli- 
cacy of the lungs ; had married when very young ; had feeble children ; had lost 
most children; had suffered from anxiety; had had measles, scarlet fever, and 
whooping-cough ; had not worn flannel next the skin ; had a very defective edu- 
cation ; were of susceptible temperament ; had brown eyes, florid complexion, 
and fleshy habit, and had suffered from coldness of the extremities. — Medical 
Times and Gazette, April 5, 1862. 

32. Brass Founders' Ague ; Disease 'produced hy Fumes of Zinc. — Dr. 
Greenhow, in a paper read before the Eoyal Medical and Chirurgical Society 
(Feb. 11, 1862), stated that this disease had first fallen under his observation 
during a brief holiday visit to Birmingham in the autumn of 1858, and he had 
subsequently been able on several occasions to investigate its history and causes 
in Birmingham, Wolverhampton, Sheffield, and Leeds. The symptoms have, as 
the name implies, some resemblance to an imperfect paroxysm of ague ; but they 
differ from it in this respect, that the paroxysms occur irregularly, and are dis- 
tinctly traceable to exposure to the fumes of deflagrating zinc. The attack 
commences with malaise, a feeling of constriction or tightness of chest, some- 
times accompanied by nausea. These always occur during the after-part of a 
day spent in the casting-shop, and are followed in the evening or at bed-time by 
shivering, sometimes succeeded by an indistinct hot stage, but always by profuse 
sweating. The sooner the latter follows the setting in of the cold stage, the 
shorter and milder is the attack, and the less likely is the caster to be incapaci- 
tated for work on the following day. Headache and vomiting frequently, but 
by no means always, accompany the attack, which at the worst is only ephemeral ; 
but the attacks are sometimes of frequent occurrence. Persons who have but 
lately adopted the calling, or who only work at it occasionally, and regular brass 
founders who have been absent from work for a few days, are more liable to suffer 
from this disease than those who work at it continually. The men themselves 
attribute this disease to inhaling the fumes of deflagrating zinc, and there can 
be no doubt that their opinion is correct ; for, on the one hand, several other 
classes of operatives are habitually exposed while at work to conditions exactly 
similar to those of the brass founders, except the liability to inhale the fumes of 
zinc, and yet do not suffer from this ailment ; and, on the other hand, brass 
founders suffer from it in almost exact proportion to their liability to inhale 
these fumes. The results arrived at by the author of the paper are — 1st. That 
brass founders, and, doubtless, other operatives exposed to the fumes of defla- 
grating zinc, are liable to suffer from symptoms resembling an irregular kind of 
intermittent fever. 2d. These symptoms consist of malaise, listlessness, aching 
of the limbs, nausea, headache, and shivering, with occasional vomiting, followed 
sometimes by febrile reaction, but always by profuse sweating. 3d. The severity 
and frequency of the attacks are much influenced by the regularity with which 
men work in the casting shops, those who work steadily at the occupation 
appearing to acquire a tolerance of the poison, which is, however, only tempo- 
rary, seeing that after a few days' absence from work even the most seasoned 
casters are apt to have an attack of the metal ague on being again exposed to 
the fumes of deflagrating zinc. 4th. The severity and frequency of the attacks 
depend mainly upon the quantity of zinc fumes evolved into the atmosj)here of 
the casting shops, those men who mix the metals, and especially those who use 
a large quantity of zinc in their castings, being much more liable to sufifer than 



1862.] Medical Pathology and Therapeutics. 



239 



those who merely re-melt brass bars, or make brass containing- but a small pro- 
portion of zinc. 5th. Any cause which tends to retard the dispersion of the 
fumes into the atmosphere — such as a close ill-ventilated workshop, or foggy 
weather, or a high wind that beats back the fumes into the shop — increases the 
liability of the casters to suffer from metal ague. 6th. Although the cold stage 
is usually preceded by well-marked prodromata, slight causes, such as getting 
into a cold bed, or any trifling derangement of the health, are apt to excite a 
paroxysm of brass founders' ague in persons already predisposed to it by habitual 
exposure to the fumes of deflagrating zinc. 7th. Operatives, such as makers of 
galvanized iron-ware, who work over molten zinc below the temperature of 
deflagration, enjoy an entire immunity from this disease. — Med. Times and Gaz., 
March 1, 1862. 

33. Sudden Death/mm Emboli. — A woman, 27 years of age, whose occupa- 
tions compelled her to be constantly standing, had suffered for several years 
from large varices, which occupied the left saphena vein from the foot to the 
bend in the groin. At the end of November she was affected for the third time 
with inflammation of the saphena, and entered the Charity, under M. Briquet. 
The vein throughout its whole course and principal divisions was completely 
filled with coagulated blood, constituting large indurated cords, the skin cover- 
ing them being red and thickened. By position, emollients, and similar means, 
the inflammation and fever were got under, and the patient was thinking of get- 
ting up in a few days, when on December 8, after an excellent night, she was 
seized by an undefinable sensation, and uttered a cry of alarm. She was found 
to be extremely pale, her features having undergone marked changes. Her 
arms were convulsively moved, she complained of intense pain in the chest, and 
in a state of the greatest alarm declared she should be suffocated. The pulse 
was filiform, the heart beat tumultuously, but without abnormal sound, and she 
died at the end of twenty minutes. The external saphena, as well as its prin- 
cipal divisions, was filled by a hard, blackish coagulum, which adhered to the 
reddened walls of the vein, and extended as far as the commencement of the 
left iliac vein. The deep saphena was free, and the blood it contained was quite 
fluid. The iliac vein and the vena cava were quite free from obstruction, and 
nothing abnormal was found in the heart or its cavities. But when the pulmo- 
nary artery was opened, a coagulum was found folded back upon itself, and 
occupying all the space between the sigmoid valves and the bifurcation of the 
artery. The coagulum was quite free within the artery, and the walls of this 
vessel, as well as all the endocardium, were perfectly white and polished. The 
coagulum, fifteen centimetres long, was of a much less diameter than that of the 
artery, its calibre being that, in fact, of the iliac vein. It in nowise resembled 
the concretions which are sometimes found in the pulmonary artery, being red 
and very hard, and consisting internally of coagulated fibrine. The lungs were 
pale, and almost bloodless ; and there were no other appreciable morbid changes. 
The deep veins of the leg and thigh were of normal volume and appearance, 
and contained only fluid blood. There can be no doubt, M. Briquet observes, 
that a coagulum detached from that which filled the femoral vein, was carried 
into the iliac vein under the influence of the ascending venous current. Re- 
maining movable and unattached to the walls of the iliac vein, when the patient 
was placed in the horizontal posture it entered the heart, and thence the pul- 
monary artery, when applied against the arterial bifurcation, it simultaneously 
arrested circulation and respiration, and gave rise to sudden death by syncope 
and asphyxia. — Med. T. and Gaz., March 22, 1862, from Gaz. des Hop., No. 25. 

34. Case of Syphilitic Disease appearing in two Healthy Children after 
Vaccination from a Syphilitic Child. — Dr. N. J. Haydon relates [Med.. Times 
and Gaz., March 29, 1862) the following examples of this, which are interesting 
as bearing upon the question now in dispute as to the possibility of syphilis being 
communicated with the vaccine virus : — 

"In the summer of 1843 1 was called, as the medical officer having charge of 
the sick poor of the parish and borough of Bodmin, Cornwall, to attend" two 
young children of different families, and living about a quarter of a mile distant 



240 



Progress of the Medical Sciences. 



[July 



from each other. The children were each of them from nine to ten months old. 
The history of their illness being precisely similar, one description vrill apply to 
both. On the first introduction of the compulsory vaccination system, the guar- 
dians of the Bodmin Union entered into a contract with one medical man to 
perform the vaccinations for the whole Union. This gentleman, in the discharge 
of his duty of public vaccinator, attended at the appointed room in Bodmin, and 
on that particular day vaccinated those two children, taking lymph from the arm 
of a child he had vaccinated the preceding week ; he appeared (from the most 
careful personal investigation which I made of this matter at the time) to have 
vaccinated no other than those two children on the day in question, and to have 
taken lymph from no other child, but the particular one alluded to. Between 
the second and third week after the vaccination had been performed, I first saw 
the children. They were literally covered with large phlyzacious pustules, the 
irritation was most intense, and, between rubbing and scratching, the head and 
nates were raw and ulcerated. No treatment had any avail, and both these poor 
children died a few days after I first saw them. Being at once impressed that 
the disease of these children was syphilitic, I made the most carefal investigation 
I could into the whole matter. In both families there were other older children 
perfectly healthy. The parents, in both cases, were labourers, of most healthy 
appearance, and of good character ; were then, most certainly, and I have no 
cause to doubt ever had been, free from syphilitic taint. The respective mothers 
of both children carried their infants themselves to be vaccinated : they saw the 
operation performed, and they saw the child from whom the lymph was taken; 
they told me the name of the child, and where it lived. As medical officer of the 
borough of. Bodmin, this child and its mother were both known to me. The 
mother had been, and, in fact, then was, on the town, and I had attended her for 
syphilis. At that very time she was diseased. I examined her child ; it had, as 
far as I could see, no primary syphilitic sores, but it had numerous syphilitic 
eruptions about its body, pustules about its nates and trunk, and copper-coloured 
leprous spots. The child was between two and three years old. and under treat- 
ment it recovered. The public vaccinator lived at a distance from Bodmin, and 
could not have known the character of the parties from whom he took the 
lymph." 

35. Value of ^gopliony as a Sign of Pleurisy. — Laennec considered aego- 
phony as a pathognomonic sign of pleuritic effusion. Skoda was the first to call 
in question this, but it remained to Prof. Landouzy to show that aegophony is 
due not to the fluid, but only to the modifications produced in the lung by the 
fluid. In a work published some years ago, he said. "^Egophonyis only a 
variety of bronchophony : it is dependent upon the modification impressed upon 
the lung by the effusion, but not upon the fluid itself." The professor now pub- 
lishes two additional cases, which, though at first sight contradictory, demon- 
strate the real conditions upon which aegophony depends. 

The following are Prof. L.'s conclusions : — 

1. ^gophony indicates compression of the lung, either by a fluid effusion in 
the pleura, or by a layer of false membrane without actual effusion. 

2. In the absence of resisting false membranes, segophony disappears or dimi- 
nishes on the removal of the effusion. 

3. When false membranes are present, segophony increases immediately after 
thoracentesis, but diminishes gradually with the yielding of the membranes. — 
Ed. Med. Journ., April, 1862, from Archives Generales, December, 1861. 

36. Tcenta Solium. — M. Mauche has observed twenty cases of t(E7iia solium 
among the soldiers of the 16th battalion infantry chasseurs, recently returned 
from Syria. Most of the patients have expelled slender portions of the para- 
site, with or without the head, armed with three hooks, the distinctive character 
of the T. solium. One patient only passed two whole worms. The kousso 
succeeded almost always when the three following precautions were taken: 1st, 
that fragments of the worm should have been passed shortly before commencing 
the use of the medicine ; 2d. that the kousso is prepared the day it is to be 
taken; 3d, that the patient observes a rigid diet for from 12 to 2i hours pre- 



1862.] 



Medical Pathology and Therapeutics. 



241 



viouslv to taking the medicine. The decorticated fresh seeds of the pumpkin 
rubbed up with sugar were used in some cases. This remedy was longer in 
expelling the worm and less effectual. It generally did not expel the worm 
earlier than 24 to 30 hours. The anthelmintic opiate composed of 125 grammes 
of honey and 20 grammes of turpentine also was useful, but it was less certain 
than the kousso. — Joimi. Heodom.. 24 March, 1862, from Becueil de M6m, de 
M6d. de Chirurg. et de Pharm. Jlih't., torn. vii. 3d serie. 

37. On the P rohabilities of the Duration of Life in the Apoplectic ami the 
Phthisical — Dr. Beuckxer has collected materials for determining statistically 
the probabilities of life in the apoplectic and phthisical. 

The results of his observations in the case of persons threatened with apoplexy 
are the following : Fatal cases of apoplexy are on the increase; therefore the 
danger in our day is greater than it was in the last century. Hamburg appears 
to be the most dangerous residence for such persons ; London is safer ; moun- 
tainous countries are the safest. The country is less dangerous than towns. 
Winter is the most dangerous period for these persons ; spring and autumn are 
less dangerous ; summer is the safest. The first year of life presents the greatest 
danger from this cause ; it goes on diminishing till the tenth year, and increases 
rapidly from fifteen to twenty. From this time it increases more slowly up to 
forty years, when it increases rapidly. About the sixtieth year the greatest 
increase of danger takes place ; it only increases slowly from this time to seventy- 
five. From this age, the danger of apoplexy gradually diminishes. The years 
48, .i8, 66. are peculiarly dangerous. On the other hand, there is little danger 
of dying of apoplexy in the years 46 and 49. The male sex is (with the excep- 
tion of London) generally more exposed to apoplexy than the female, particularly 
between the ages of thirty and fifty: whilst up to twenty, and then after sixty, 
there is proportionally more danger for the female sex. During the middle and 
earlier years of life, the well-to-do classes are in greater danger of apoplexy than 
the population in general. TThere intermittent or pituitary fevers prevail, the 
danger appears to be greater. Sudden change of weather appears to increase 
the danger, as also does rain, whilst fogs (London) do not appear to have this 
eff'ect. 

TTith regard to the probabilities of being attacked with and dying of phthisis, 
Dr. Bruckner's inquiries give the following results : The danger of death from 
phthisis is not so great at present as it was in former times. The female sex is 
in greater danger of phthisis than the male : London and Berlin are exceptions. 
This is particularly the case in youth, and up to the fortieth year; whilst in later 
life the danger diminishes more rapidly in the female sex than in the male. 
Persons who. from the nature of their employment, are exposed to the inhalation 
of dust, especially of mineral particles, are in great danger. Those who freely 
employ the organs of voice, or the muscles of the chest, particularly in the open 
air, are exposed to the least danger. Phthisis appears to be most frequent in 
the two temperate zones. In countries where inflammatory affections of the 
chest are endemic, the danger of phthisis is inconsiderable : these diseases, when 
endemic, exclude one another. In countries where intermittent fever is endemic, 
the danger of consumption is great: these diseases do not exclude one another. 
At "a height of 1800 to 3000 feet above the sea (in dry mountain air), the danger 
of becoming phthisical is slight ; in low marshy districts, on the other hand, the 
danger is great. 

With regard to the probable duration of life of such persons as are doomed, 
to die of phthisis, Dr. Bruckner has deduced from his statistical investigations 
the following conclusions : In a person of phthisical constitution, the dauber of 
becoming affected with consumption increases up to the twentieth year, when it 
has reached its highest point. The danger may be reckoned as equal to 21.05 
years of life, so that such a person at the age of 23 years has the same expect- 
ancy of life as a healthy individual at 44. From the thirtieth year, when it may 
be reckoned as equivalent to 17.42 years of life, the danger goes on diminishing. 
In the fortieth year it is equal to 13.94 years, in the fiftieth to 7.23 only. In the 
seventieth vear the danger is at an end, a person of a phthisical constitution 
No. LXXXYIL— July 1862. 16 



242 Progress op the Medical Sciences. [July 

having the same prospects of life as any other individual of that age. Under 
similar circumstances, phthisical persons of the female sex die more rapidly and 
at an earlier age than males. The female sex reaches some years earlier than 
the male its highest point of mortality from phthisis. 

If a person is actually affected with phthisis, his probable duration of life is 
21 months and 9 days. A pregnant woman, during the duration of her preg- 
nancy, is not likely to die of phthisis. After delivery, a consumptive woman 
has probably not more than six weeks to live. For all phthisical persons, the 
danger of dying is considerably greater in spring, less in summer and winter, 
and least of all late in summer, towards autumn. If a phthisical person removes 
from a warm to a cold climate, the danger of death is thereby greatly increased. 
— Edin. Med. Journ., Jan. 1862, from Canstatfs Jahreshericht, 1861. 



SUKGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

38. Treatment of Burns. By Prof. Roser. — In truth, there can scarcely be 
said to be any special treatment of burns, the loss of substance resulting from 
their influence being repaired by the same processes as prevail after any other 
form of destruction of the cutaneous surface. Much depends upon the depth 
to which the injury has extended, for while a destroyed epidermis is rapidly 
reproduced, when the skin has suffered to a great depth, or throughout its 
entire substance, the reparation, after the separation of the mortified parts, 
may be very tedious, in consequence of the great loss of substance, or of the 
unsuitable character of the parts affected for cicatricial formation. The con- 
traction after cicatrization is also often great, both from this loss of substance 
and from the position of the parts, as in the bend of the limbs, being favourable 
to such contractile action. It is, however, an error to suppose that greater con- 
traction follows burns than takes place from similar loss of substance from other 
causes. When the skin has been destroyed only through a portion of its sub- 
stance, this contraction is not observed, only smooth cicatrices analogous to 
those of smallpox being present. 

Not only is the- period required for reparation and cicatrization after burns 
dependent upon the depth to which the injury has extended, but it is still 
more so on the inflammation of the skin which it has given rise to. This may 
affect not only the part actually burnt, but the adjoining parts, and may give 
rise to a secondary destruction of the skin, or at all events obstinate suppu- 
ration, which will delay the healing process, this then assuming a remarkably 
chronic character. Although it is this last circumstance which by its complexity 
and its consequences chiefly renders our prognosis uncertain, yet the other 
point, the determination of the depth to which the burn has extended, is by 
no means always an easy matter at first, even for the most experienced observer. 

When the epidermis is merely lost or raised up into bullae, the treatment of 
burns is simple enough. The serum should be discharged from the bladders by 
small punctures, without removing the epidermis. The necessity of covering 
the exposed nervous papillse explains the success of various empirical applica- 
tions ; and even the solution of nitrate of silver acts only in this way. The 
exposed cutis becomes covered with a thin layer of gelatinizing albumen, and 
the deposit which ensues upon the application of the nitrate solution produces 
a protective crust. Lead and chalk waters act in the same way, and cotton 
wool, the most suitable and simplest of all dressings, thus protects the exposed 
parts from the action of oxygen, and from mechanical contacts. 

After two or three days, the physiological condition of the parts is different, 
the exposed papillae having, in consequence of a growth of cells and vessels, 
become covered with a protective covering. The excessive sensibility has 
diminished, suppuration may have occurred, and perhaps here and there, deeper 
penetrating inflammatory action has been set up. We have now to seek whether 



1862.] 



Surgery. 



243 



we can moderate this inflammatory action, and favour the formation of epider- 
mis. But, in fact, we can do little in the matter. If the injury is superficial, 
the healing will soon take place, under the use of the most different and some- 
times absurd means ; while if the inflammation has penetrated deeply, do what 
we will, the cure will be slower. We may resort, according to circumstances, 
to various local antiphlogistic applications. When the mortification of the skin 
is only superficial, it is quickly thrown off, leaving a retiform granulating surface, 
and art has here little to do beyond protecting the parts from injury. When 
the mortification extends deeper, we have no specific means for hastening the 
suppuration of parts which must precede separation. Such separation is a phy- 
siological process, and our intervention is limited to the prevention of its being 
obstructed. But the separation having taken place, have we any means of 
hastening the growth of granulations or of repressing them when too luxurious ? 
Physiology and clinical experience alike declare that nothing need be done. 
The granulations, if too prominent, will afterwards recede without the aid of 
caustic ; and the smoothest cicatrices will be found in those cases in which least 
interference has taken place. When, however, the wound is advancing towards 
cicatrization, the condensation of the connective-tissue, and its covering with 
epidermis, are much favoured by a protective covering of adhesive plaster. 

In the extremest degree of burns, when the skin is destroyed throughout its 
entire substance, we have to do with a condition of great surgical importance, 
cicatricial contraction, which although of the highest utility in lessening the 
surface of the wound in some cases, proves in others of the most serious detri- 
ment. The employment of adhesive plaster is of great service in regulating 
this contractile power of the cicatrix. Thus, suppose a longitudinal loss of 
substance on the anterior surface of the index finger exists, there is no better 
means of regulating the direction of the cicatrix which will ensue, than sur- 
rounding the whole finger by small strips of plaster. These act in three ways. 
1. The circular application displaces the skin from left to right, and favours the 
formation of the cicatrix in the transverse direction, in which no contraction 
can occur. 2. Contraction in the longitudinal direction is also prevented by 
the finger being kept stiffly bound up" so that its flexure is difficult. 3. The 
plaster exerts a very decided influence in preventing or remedying that projec- 
tion of the cicatrix, which is so remarkable after longitudinal loss of substance 
at the bend of joints and in the neck. In the same manner, in the most various 
parts of the body, we may obtain from the use of plaster beneficial effects which 
no other means will furnish. So also the contractions supervening on burns 
which have been improperly treated, are so easily, rapidly, and completely reme- 
died by the methodical application of plaster, that the cases must be seen to 
obtain belief. Most aggravated cases, which those unacquainted with this sim- 
pler means would suppose to be amenable only to the knife, and others for which 
this has been in vain resorted to, have readily yielded to the application of 
plaster. It was Mr. Tamplin who first drew attention to this mode of treat- 
ment, and Professor Poser's experience has amply confirmed the truth of his 
statements. He has been quite astonished at the success which attends the 
treatment of the worst cases of contraction of the fingers. The plan consists 
essentially in surrounding the part with small strips of plaster, and making 
counter-pressure at the contracted flexures by means of small balls of cotton 
wool. — Brit, and For. Med.-Chmrg. Review, April, 1862, from Archiv. der 
Heilkunde, No. 1, 1862. 

39. Traumatic Tetanus cured by Chloride of Barium. — Dr. Gnecchi, of 
Milan, relates the following example of this : — 

A hairdresser, thirty-nine years of age, cut himself in the palm of the left 
hand, about the beginning of March, 1858. The wound healed in six days, and 
there was no bad consequence until the morning of the 30th of March, when, on 
getting out of bed, he began to feel a difficulty in opening the mouth, a contrac- 
tion of the left hand with impossibility of extending it, with pain in the right 
flank and thigh. For the first few days these symptoms disappeared when the 
patient lay down in bed, but returned when he got up and exposed himself to 
the air. On the 10th of April, as the symptoms were increasing in severity, the 



244 



Progress op the Medical Sciences. [July 



patient was admitted into the principal hospital of Milan. Next morning there 
was spasmodic contraction of the masseters, with rigidity of the muscles of the 
neck ; the left hand contracted as soon as the arm was removed from below the 
clothes, while the pain in the flank and thigh persisted. The pulse was but little 
increased in frequency. Chloride of barium was prescribed in the form of six- 
teen grains of the salt in a pound of distilled water, to be taken in the course of 
the twenty-four hours. This dose was continued till the 31st, when, as the 
tetanic symptoms had almost disappeared, it was reduced to eight grains. The 
medicine was discontinued after the 26th April, and on the 28th the patient was 
dismissed cured. 

In connection with this case, it may be stated that Dr. Gnecchi has since 
succeeded several times in curing traumatic tetanus with this preparation of 
barium, that Dr. Gherini failed, but that Dr. Tassani succeeded in the case of a 
man wounded in the Italian war. — Ed. Med. Journ., April, 1862, from Gazette 
3Ied. Ital. Comb., and Gaz. des Hop. 

40. The Ififluence upon the Growth of the Bones of Paralysis, Disease of 
the Joints, Disease of the Epiphysial Lines, Excision of the Knee, Rickets, mid 
some other Morbid Conditions. — Dr. G. M, Humphry read a paper under the 
above title before the Royal Medical and Chirurgical Society (April 8, 1862). 
It consisted chiefly of the account and measurements of numerous cases and 
specimens, and the following are the principal conclusions : Paralysis is usually 
attended with a deficiency in the growth of all the bones of the part affected ; 
this is most marked in the segments where the paralysis is most complete. Its 
effect, however, is very irregular. Disease of an important joint, causing anchy- 
losis or preventing movement in the joint, is often attended with imperfect 
growth throughout the limb, most marked, however, in the segments contiguous 
to the diseased joint. It is probable that anchylosis of the hip, in childhood, 
may induce deficiency of growth on that side of the pelvis, and so be a cause, in 
the female, of difficult parturition. The author has not, however, been able to 
substantiate that point, and would be obliged by information bearing on the 
question. Disease in the epiphysial lines of bones deserves more attention than 
has usually been given to it. It is often, though not always, followed by impair- 
ment of the growth of the bone affected, and sometimes of the whole limb. It 
is most frequent and most deleterious at the lower end of the femur, where the 
growing process is more active and longer continued than in any other part of 
the body. In a segment of a limb where there are two long bones, as the fore- 
arm or leg, and one of them is stunted by disease, the other commonly is so too, 
but not necessarily. Thus the fibula sometimes outgrows the tibia, and runs 
below, or ascends above, its proper level with regard to it. Excision of the 
knee, if the epiphysial lines are removed, is followed by marked arrest of growth 
in all parts of the Hmb. If the epiphysial lines are spared, the growth, in most 
instances, keeps pace with that of the opposite limb. In some cases this is not 
so, owing, perhaps, to the effect of the preceding disease upon the limb, or to 
the epiphysial lines becoming involved and destroyed in the suppurative pro- 
cesses that follow the operation. Hence the proper growth of the limb, after 
excision, cannot be calculated on with certainty in any particular case. Still 
the short limb, even when there is a considerable difference between it and its 
fellow, is commonly so useful that the fear of arresting the growth of the limb is 
not a fatal objection to the operation in young subjects ; and, after the age of 
fifteen or sixteen, it need scarcely to be taken into account. Rickets is charac- 
terized by a want of proper growth in bones, even more decidedly and more 
uniformly than by preternatural curvatures in them. The imperfection is com- 
monly noticeable, more or less, in all parts of the skeleton ; but is most marked 
in the limbs, and most of all in the proximal segments of the limbs. These 
segments of the limbs — i. e., the thigh and the arm, grow more quickly after 
birth than other parts of the body ; and the want of growing power attendant 
on rickets tells accordingly in a peculiar manner upon them. A bulging and 
knottiness at the epiphysial lines is a common feature in rickets, and is apt to 
be mistaken for swelling of the ends of the bones, which is very rare, except in 
the intra-uterine and infantile periods. This bulging is due to the calcification 



1862.] 



Surgery. 



245 



of the epiphysial stratum of cartilage not taking place in a proper manner, so 
that the part yields, or is squeezed out, and then undergoes ossification. The 
condition is most frequently observed at the lower end of the femur and at the 
upper end of the humerus. — Med. Times and Gaz., April 19, 1862. 

41. Ligature of the Common Carotid. — Dr. Redfern Davis, of Birmingham, 
communicated to the Medico-Chirurgical Society of Edinburgh the following 
case : — 

" About two years ago I was sent for during the night by a physician, to see 
a man, who, in a paroxysm of jealousy, had just cut his throat with a pocket- 
knife. 

" When I arrived, I found the patient lying on a bed, whither he had been 
removed. On the floor of the room was a large quantity of blood, and the bed- 
clothes were sprinkled with the same fluid. The man, who, from loss of blood, 
was very pale and feeble, presented on the left side of the neck, just below the 
angle of the jaw, a rugged, transverse incision of about two inches in length. 
The windpipe and gullet were uninjured. For about half an hour I vainly 
strove to discover the source of hemorrhage, succeeding only in finding some 
two or three small arteries, which I ligatured, but without materially, if at all, 
lessening the flow of blood. 

" Finding that the man was gradually getting weaker, and that by compressing 
the common carotid artery the hemorrhage was completely stopped, I deter- 
mined to tie that vessel. 

" I had previously made up my mind that, should a case occur where I was 
called upon to tie the artery, and should the place of selection be left to my 
own choice, I should ligature it in the cellular interval between the two heads 
of origin of the sterno- mastoid, as originally proposed by a French surgeon. 
Accordingly I did so, and found the procedure very easy, although certainly 
some difficulty was occasioned by the deficiency of light, one farthing candle 
being all I could procure. I interfered as little as possible with the cellular 
sheath of the artery. The artery was tied with a hempen ligature, as T feared 
to employ a metallic one, in case, if any accident should occur, it might be 
ascribed to its use. I had not at that time so much confidence in metallic 
ligatures as, from their constant employment, I have since acquired, or I should 
not have hesitated to use a silver wire, as I did some months ago in tying the 
popliteal artery, and as I am always in the habit of doing in cases of amputation. 
After the artery was tied, the bleeding entirely ceased ; and the wound having 
been dressed, the patient fell asleep, and continued sleeping till nearly the middle 
of the following day. As a precaution, however, I left my own dresser to remain 
in the house. 

" The ligature came away on the twenty-first day, the wounds healed up en- 
tirely a few days afterwards, and my patient resumed his duties, which were very 
light, in two months from the receipt of the injury. 

" During the whole time nourishing diet was prescribed, but no wine, spirits, 
or malt liquor was allowed. 

" The feature in this operation to which I would especially draw the attention 
of the society is the position where the common carotid was tied — a position 
which I think presents the following advantages over the situations where it is 
usually ligatured : — 

" 1. The superficial position of the artery, enabling the surgeon to come directly 
upon it. 

" 2. The muscles, not requiring to be turned aside, are in no way disturbed. 
Though this makes little difference at the time of the operation, it subsequently 
aids the free escape of pus. 

" I am aware that an objection may be raised on account of the position of 
the jugular vein; but it must be remembered that in the above case, in con- 
sequence of the previous loss of blood, the size of that vessel was very much 
diminished, and it therefore was not calculated to occasion that amount of in- 
convenience which it otherwise might have done. During the operation I never 
saw it; and had it been troublesome, it would have been very easy to have 
restrained its swelling by means of the fingers of the left hand, according to the 



246 



Progress of the Medical Sciences. [July 



procedure reeoinmended in tying the common carotid artery." — Edinh. Med. 
Journ., January, 1862. 

42. Operations for the Cure of Varicocele and Varicose Veins. — Dr. M. H. 
CoLLis, in an interesting "retrospect of the progress of surgery during the last 
decade," makes the following remarks on this subject : — 

" Operations for the cure of varicocele and varicose veins are at present in 
great repute in France and England. The simplest and least dangerous of 
these are Vidal de Oasis', Lee's, Erichsen's, Startin's, Eicord's, and Tufnell's 
methods. 

" Yidal inserts a pin behind the veins, and a wire in front of them, but through 
the same apertures in the skin ; the wire is passed through holes in either end 
of the pin, and the two being twisted, the veins are compressed and gradually 
cut through. 

"Lee' passes two needles under the veins, and applies the twisted suture for 
a few days, until the vein is filled with a coagulum between the sutures ; he then 
divides the vein subcutaneously. 

" Erichsen^ substitutes, for Yidal's bar and wire, a simple loop of wire, which 
he gradually twists until it cuts its way out. 

" Startin^ uses what he terms a bar-needle and clasp, which are convenient for 
many operations besides those on varicose veins. The bar-needle has a straight 
shaft and a curved extremity ; the latter enables the operator to pass it readily 
under the vein, the former enables it to compress the vein when passed through. 
The clamp is a piece of wire with a loop at either end, which acts as the thread 
in the figure of eight suture. 

"Ricord makes use of two loops of hempen thread which are passed in oppo- 
site directions — one over and the other under the veins ; the ends of each ligature 
are then passed through the loop of the other ligature, and drawn tight. 

"Mr. Redfern Davies^ and Mr. TufnelP substitute wire loops for thread ; and 
the latter surgeon adds what he calls 'retracting guides.' These are simply 
threads of wire which are attached to each loop, and which enable the surgeon 
to lessen his compression of the vein whenever he pleases, or to remove the 
ligature entirely. 

" Mr. Davies found it impossible to remove the wire ligatures, in one instance, 
and was obliged to cut them close off, and leave them in the man's scrotum, 
where they appear to have permanently remained without the patient being 
incommoded by, or even conscious of, their presence. 

"All these modifications of metallic ligature are preferable to incision, exci- 
sion, or caustic, though none of them are free from danger. In operations on 
varicose veins in the leg, it is advisable to place a pad on the vein above and 
below the point operated on, so that blood may not lodge there. There is no 
greater cause of troublesome and dangerous phlebitis than the presence of coagula 
in the veins. The danger may be reduced materially by the use of compresses ; 
but in no case can operations on veins be considered other than uncertain and 
dangerous. In varicocele the use of elastic compresses and suspensories, cold 
douching early and late, and abstinence from the general exciting cause will cure 
many bad cases, and that with a surprising rapidity. The use of bromide of 
potassium (if it can be obtained pure) as an antaphrodisiac, in combination with 
iron, if necessary, is a useful adjunct ; and everything should be tried before 
risking the patient's life by operation. 

" If the mortality were not more than one per cent, we should not be justified 
in letting our patient run even that small risk until all other means had failed. 
In varicose veins of the leg, the most perfect obliteration will not always cure 
the ulcers which have called for the operation ; and if we knew but all relapses 
will be found to occur after ligature of the spermatic veins, not to speak of the 



' Medical Times and Gazette, January, 1853, &c. 

' British Medical Journal, February, 1860. 

^ Medical Times and Gazette, May, 1860. 

« Lancet, .July 20, 1861. 

* Dublin Quarterly Journal, November, 1861. 



1862.J 



Surgery. 



247 



possible atrophy of the testis, for whicli our patient would not thank us. For 
the leg. a broad band of vulcanized India rubber tightly encircling the limb 
below the knee, as recommended by Professor Hargrave, will sometimes eflPectu- 
ally compress the superficial veins, and drive the blood into the deeper channels, 
especially in thin subjects, and the plan is unattended with risk, and may fairly 
claim a trial." — Dublin Quarterly Journ. Med, Sc., May, 1861. 

43. Stability of tJie Cure of Varices. — M. Blot communicated to the Society of 
Surgery two cases of the spontaneous cure of large varices occurring in pregnant 
women. They were seven months advanced, and although the tumours formed 
by the veins were large, hard, and red, these entirely disappeared by means of 
mere rest, cataplasms, and the use of an inclined plane. They returned neither 
before nor after delivery. M. Chassaignac doubted the propriety of the term 
radical cure applied to these cases by M. Blot ; for how often do we find the 
blood resuming its course in veins which had been temporarily obliterated by 
inflammation. The coagula produced by coagulating substances do not either 
assure a definitive cure of varices, as they always become absorbed. M. Chas- 
saignac is even sceptical with respect to the radical cure of hydrocele by means 
of irritating injections ; for he has found the fluid reproduced in the tunica 
vaginalis, although this at first had been completely obliterated, and had abun- 
dantly suppurated. M. Yelpeau declares that relapse after the operation for 
hydrocele did not take place oftener than in four per cent., whether there had 
been obliteration of the tunic a-vaginalis or not, such obliteration, especially 
definitive, being, indeed, very rare. With respect to the radical cure of varices 
he is more disposed to agree with M. Chassaigaac, inasmuch as the obliteration 
of the veins, whether produced by the perchloride of iron, caustics, or ligature, 
and which is often so difiicult to effect, is not after all durable. The varices are 
reproduced. Such reproduction may take place even after excision of the vari- 
cose veins ; for M. Yelpeau has seen the saphena vein reproduced ten years 
after such an operation. This M. Broca regards as an illusion on the part of 
M. Yelpeau. for, as M. Yerneuil has shown, in the great majority of cases, this 
large vein which is taken for the saphena is not that vein, but a varicose colla- 
teral, taking the same direction as the saphena. With respect to the stability 
of the obliteration of the veins, we should distinguish whether this has been 
produced by means of coagula or by adhesion of the walls of the vein. Coagula 
will disappear at last, even those which have been produced by means of an in- 
jection of the perchloride ; and in one case M. Broca has known this to take 
place at the end of five years. But when the obliteration is due to the adhesion 
of the walls of the vessel, such adhesion is as solid, or even more so, than that 
■which takes place between the pleurae. M. Depaul does not regard a relapse as 
always a proof that a radical cure has not taken place. A man fractures his leg 
at the seat of a well-formed callus, but surely we should not deny that the ori- 
ginal fracture had been completely -cured. With respect to M. Blot's two cases. 

■ although they certainly are examples in which the varices were cured prior to 
delivery, they would have been of more value as examples of radical cure had 
they not occurred in the persons of pregnant women, in whom varices habitually 
disappear at the termination of pregnancy. M. Depaul added the observation 
that the production of varices in pregnant women is not solely due to a mechan- 
ical cause, for these varices sometimes appear long before the uterus has attained 
a size sufficient to compress the pelvic vessels. There is therefore also some 
special cause, the nature of which is as yet unknown. — Gazette Hebdomadaire 
de Med. et de Chirurg., 18 April, 1862. 

44. True Anchylosis of the Left Hip- Joint, from Rheumatism ; the limb at 
a right angle to the body, and abducted ; excision of a vjedge-shaped piece of 
the femur; cure. — Dr. H. AY. Berend, of Berlin, recently (21 April, 1862) 
communicated to the Academy of Sciences, through M. Yelpeau. a case of 
this. The condition of the patient was such as to render impossible the usual 
orthopedic method of treatment. Myotomy would have been useless, and violent 
extension would have subjected the patient to the danger of a serious fracture 



248 



Progress of the Medical Sciences. 



[July 



of the pelvis. M. B. therefore determined to perform Barton's operation, which 
he did as follows : — 

The patient having been pnt under the influence of chloroform, was laid 
on his right side. An incision down to the bone was then made three inches 
long, commencing a little above the great trochanter, and extending trans- 
versely and outwardly, regarding the anomalous position of the limb, it being 
in a state of abduction and flexed to a right angle. The bone was then 
denuded and divided by a Charriere's saw and the knife saw, which Dr. B. pre- 
fers to the chain saw on account of the difficulty of inserting this last between 
the bone and the soft parts. A cuneiform portion of bone was removed, the 
base of which was three-quarters of an inch. No hemorrhage followed the 
operation. The wound was united by silk and silver ligatures ; and compressing 
bandages were applied to prevent hemorrhage. 

During the first six days the patient had moderate fever, and he was kept 
upon an antiphlogistic diet. On the sixth day the ligatures were withdrawn. 
After this nothing remarkable occurred except frequently recurring erysipelas 
of the thigh operated on. dependent upon proiracted fetid suppuration from the 
bottom of the wound. This was successfully treated by the prolonged use of 
cataplasms and a small incision at the anterior portion of the thigh. " 

Nine months after the operation Dr. B. commenced certain gymnastic move- 
ments, with a view of maintaining the mobility of the false articulation, and at 
the same time to strengthen the limb. 

Eleven months after the operation the patient was entirely cured, and was 
exhibited to many societies of Berlin. The deformity had disappeared, and the 
patient could take the longest walk without any other support than a small 
stick and without limping. — Gazette Hehdomadaire, May 2, 1862. 

This operation, first performed by Dr. J. Ehea Barton, of Philadelphia, has 
since been practised by the late Dr. J. Kearney Rogers, of Xew York, and also 
by Maisonneuve in France, by Ross in Holstein, by Textor and Waller in Ger- 
many, and now by Berend. 

45. Dislocation of the TJlna forwards, witlioid Fracture of the Olecranon. — 
It has generally been supposed that dislocation of the ulna forwards cannot take 
place without fracture of the olecranon. This idea, however, it is observed by 
the editor of the article "Dislocation," in the new edition of Coopefs Surgical 
Dictionary, "is doubly incorrect; inasmuch as there are at least six well 
authenticated cases of the dislocation loithout the fracture, and only three pub- 
lished cases in which the two were combined." To the cases of dislocation 
without fracture of the olecranon must be added a case related before the Societe 
de Chirurgie in Paris on July 31st. 

On April 19th. a lad, aged 15, had his arm and hand caught in a mill. The 
hand was slightly lacerated; the forearm was broken at the middle ; there was 
not much swelling of the cIIdow, and a luxation forwards was readily detected. 
The back part of the elbow was flattened ; the processes of the lower end of the 
humerus, especially the epitrochlea. projected considerably; the forearm was 
half bent, and could be extended and flexed, but with great pain ; the olecranon 
could be distinctly felt in front of the elbow. M. Caussin, in whose care the 
case was, attempted to reduce the dislocation by extension. Failing in this, on 
account (as he supposed) of the shortness of the leverage which was left in 
consequence of the fracture, he forcibly flexed the elbow over the arm of an 
assistant, and soon reduced the luxation. The patient was able to resume his 
work in forty days. — Brit. Med. Journ., Nov. 30, 1861. from L' Union Medicate, 
Sept. 7, 1861. 

46. Dislocation of the Foot Foriuards. — Dr. De.marquay relates {Moju'teur 
des Sciences 2Ud. et Fharm., Oct. 1, 1861) a case of this rare accident. The 
patient fell from the last round but one of a ladder which he was descending, in 
such a way that the left heel was fixed at the edge of a piece of wood, and the 
leg inclined backwards. To save himself from falling backwards, he caught a 
piece of wood with his right hand, and supported himself with the right foot. 
The left astragalus was driven forwards from its articulation with the tibia and 



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249 



fibula. When M. Demarqnay saw him, eight hours after the acciclent, he found 
the upper surface of the astragalus forming a projection in front ; the foot was 
rotated on its antero-posterior axis, so that the sole looked inwards, the external 
border rested on the bed. and the inner edge was directed upwards. The tibia 
touched the tendo-Achillis. the projection of which had disappeared ; the mal- 
leoli were displaced backwards; there was no fracture of the fibula; and the 
tendon of the peroneus brevis projected at the outer side. After having given 
chloroform so as to produce complete muscular relaxation. M. Demarquay drew 
the heel backwards, at the same time bending the foot on the leg, which was held 
fixed. This manoeuvre had to be performed several times before reduction could 
be effected. A moderately tight "bandage was applied, and kept moist with cold 
water. No symptoms of any importance occurred ; the tumefaction gradually 
diminished; and the patient recovered, with perfect use of the limb. 

47. Fracture of a Rib produced hy a Sneeze. — Dr. D. F. Castella, of Fri- 
bourg. relates the following example of this : — 

A keeper of a public-house, thirty-nine years of age. has a robust constitution, 
although he has suffered during his life from various maladies, apparently of a 
strumous nature. On the 6th November, 1861. he was seated in his bar with 
several customers, one of whom offered him a pinch of snuff, which he accepted. 
Not being in the habit of snuffing, he was at once seized with a fit of sneezinr. 
which he attempted to restrain by shutting the mouth and forcibly dilating the 
chest. In this, however, he failed, and a violent expiration having succeeded to 
the excessive and prolonged dilatation of the thorax, he felt at the same moment 
in the left hypochondriac region a sudden, sharp pain, accompanied by a very 
distinct crack, difficulty of respiration, and a very painful cough. I was at once 
summoned. 

I discovered in the middle of the body of the ninth rib on the left side a very 
evident crepitation, and an oblique solution of continuity. It was then a frac- 
ture of the second false rib on the left side. I was able to confirm this diagnosis, 
as the same symptom persisted during four or five days, with slight tumefaction 
of the surrounding soft parts. No complication in the part of the pleura or 
lung supervened. 

I am not aware that violent sneezing has been cited by authors as a cause of 
fracture of the rib. If this case is not unique, the fact must have been but 
rarely observed. It is interesting in a surgical point of view, and it is important 
in legal medicine to know that rapid and strong contraction of the diaphragm, 
preceded by an excessive and prolonged extension of that muscle, may occasion 
the fi-acture of a rib. — Glasgow Medical Journal, April, 1862, from Gazette des 
Hopitaux. 

48. Transverse Fracture of the Patella. — ^Ir. Holthouse showed to the Pa- 
thological Society of London a specimen of this, in which the fragments were 
two inches and a half apart, but united by true ligamentous tissue. He observed 
that in 18.i0, Mr. William Adams directed the attention of the Society to a 
mode of connection of the fragments of a patella fractured transversely that had 
not, up to that time, been recognized. He demonstrated that certain cases 
which were usually regarded as examples of true ligamentous union in which 
the ligament had become elongated, were in reality cases of non-union, the con- 
necting material being no new structure interposed between and uniting together 
the fractured surfaces, but simply the fascia which passes over the patella in a 
thickened condition, and having incorporated with it the bursa patella. In 
true hgamentous union the separation of the fragments is generally from half an 
inch to an inch, and Mr. Adams had not seen it exceed one inch and a half." 
The specimen exhibited was removed from a patient of Mr. Holthouse, who 
died in the Westminster Hospital ; but as the lesion was not observed till after 
death, no history of it could be obtained. A longitudinal section through the 
two fragments and their connecting mediums, showed the latter to consist of 
true ligament, two inches and a half in length, uniting the fractured surface of 
one fragment to that of the other, and inclosed between the fibrous capsule of 



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[July 



the joint on the outside, and the synovial membrane on the inside. The ligament 
was strong and thick at its attached extremities, but became somewhat thinner 
towards its centre. Mr. Holthouse observed that he considered the specimen 
worthy of exhibition on three grounds : 1st. Because it showed that a separation 
of the fragments of a broken patella to the above extent is not necessarily a 
proof of non-ligamentous union. 2d. Because it illustrated the extent to which 
the new material may become elongated ; for he supposed it would not be dis- 
puted that at one period the fragments must have been, if not in actual contact, 
at least in much closer apposition than at present, or no new uniting material 
would have been thrown out ; and 3d. Because it demonstrated the importance 
of not using the limb till the uniting medium had become sufficiently firm to 
resist the action of the muscles which flex and extend the leg. — Med. Times and 
Gaz., March 15, 1862. 

49. Statistics of Amputations at the Hospitals of Paris. — Dr. Ulysses Trelat 
communicated to the Academy of Medicine of France (March 25, 1862) the sta- 
tistical results of the greater amputations in the Parisian hospitals. These sta- 
tistics embrace the following hospitals : Hotel-Dieu, from 1850 to 1861 inclusive, 
11 years ; Piti6, from 1851 to 1861, 10 years ; Charity, from 1850 to 1861, 11 
years ; Saint Antoine, from 1853 to 1861, 9 years; Necker, fronj 1848 to 1861, 
U: years ; Beaujon, from 1850 to 1861, 11 years ; Laribosiere, from 1854 to 1861, 
8 years; I'Hopital des Cliniques, from 1855 to 1861, 7 years; I'Hopital des En- 
fants Malades, from 1851 to 1861, 10 years ; Sainte Eugenie, from 1854 to 1861, 
8 years — in all, 99 years, almost a century of hospital practice. 

Excluding some exceptional cases which are pointed out and disregarded, 
there were 1144 amputations, as follows: At the hip-joint, 3; thigh, 360; at 
the knee-joint, 4 ; leg, 418; foot, 116 ; shoulder-joint, 27 ; arm, 141 ; elbow-joint, 
4; forearm, 44; hand, 27. 

Of the whole number, death resulted in 522, or in 45.6 per cent. 

Pathological amputations, 568 ; deaths 223, or 41 per cent. 

Traumatic amputations, 470 ; deaths 261, or 55.5 per cent. 

Amputations from undetermined causes, 28 deaths, or 26 per cent. The 
smallness of this mortality results from there being included in this category a 
proportionably great numlDer of children. 

The mortality among males was 438 in 908 operations, or 48.2 per cent.; 
among females, 84 in 236 amputations, or 35.5 per cent. M. Trelat explains 
this difference, 1, by the relative fewness of operations and of severe wounds in 
the female wards. 

As to age, that which furnishes the smallest mortality is that from 5 to 15 
years, viz., 18.9 per cent., or 15.2 in the pathological amputations, and 16.6 in 
the traumatic. The mortality previous to the fifth year of life is nearly the same 
as that between the ages of 15 and 30 ; after the 15th year it increases regularly 
and without interruption, whatever may be the nature of the amputation or the 
sex of the patient. Beyond 70 years of age it becomes so large as 95 per cent., 
that is, one only recovers of twenty operated on ; hence M. T. reprobates am- 
putation in those above 70 years of age. — Gazette Hehdomadaire de Med. et de 
Chirurg., March 28, 1862. 

50. Perforating Gunshot Wound through the Thickness of the Lung ; Reco- 
very. — Dr. Wood's, R. N., records the following remarkable case : — 

Private E., Royal Marine Infantry, whilst serving in the Burmese campaign, 
was struck by a musket-bullet two inches below the right nipple. The projectile 
passed back and out through the thorax, between the fourth and fifth ribs near 
their angle, posteriorly, whence, being unable to perforate the elastic skin, it 
passed round horizontally to the median line, and lay upon the spine beneath 
the integument and facia. 

I forthwith turned the man over on his face, and cut down upon the bullet 
with a fair crucial incision. And here, I may observe, that no sugeon in the 
field fcJhould underrate the importance of extracting even a superficial bullet 
under such circumstances, especially if it be contiguous to a cavity, unless he 
has a tenaculum forceps to grasp it with : for if possible the elastic " cyst," as 



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251 



it were of fascia, enveloping the bullet, will jerk it back into its trajet, unless 
the incision be very free, and the grasp of the ball tenacious, whilst the patient 
and his comrades regard with the greatest anxiety the successful extraction of 
the bullet. And no subsequent time like the moment of being stricken, whilst 
the faculties are all engaged elsewhere, will the surgeon find equally desirable 
for operation or extraction. In this instance, I fixed the bullet against the 
underlying spine, and thus extracted it with facility. Florid arterial blood 
spurted from the wounds at each inspiration and expiration, and the same, 
mixed up with air-bubbles, was thrown out by the mouth in frequent short 
coughs. The pulse was at 130, small and fluttering ; the surface was clammy 
and cold ; and the anxiety of countenance such as one only sees in the course 
of gunshot wounds of vital organs. His mouth being parched, and utterance 
nil, I poured down his throat a draught of rum and water from my canteen ; and 
observing a portion of his shirt deficient, where the bullet had sped, I passed a 
long steel ball-probe through the wound, into the lung, which was marvellously 
insensible to the touch, but could thus discover no foreign body. 

I next applied a roller so as to fix the ribs as far as possible, leaving the 
wounds free, and I dressed the apertures but lightly with lint, so that the blood 
might flow externally, rather than that unnecessary effusion should occur within 
the pleural cavity. 

This, I am aware, is a moot point in military surgery, whether, if hemorrhage 
must occur from a wounded lung, it were better to be internal, so as to make 
pressure within the pleura on the lung ? or whether the surgeon in the field had 
better, by all means in his power, induce the arterial hemorrhage to flow exter- 
nally instead, if flow it must? The former object I, in this case, had some 
intention of trying to favour, by fixing the ribs on that side with a thin coating 
of plaster of Paris applied over a piece of lint, moistened with gum-water, and 
allowed to " set" upon the ribs, as a light "mould," in fact, trusting afterwards 
to absorption of the effused blood. However, the man's anxious expression 
caught my eye, and I concluded I had better follow the beaten track whilst his 
life hung thus upon a thread, rather than innovate, however plausibly, shut off 
as I was from consultation by several hundred miles of space. Would any 
member or members of the Surgical Society grant the favour of an opinion on 
this subject? Much arterial hemorrhage from the shot wounds, and through 
the mouth, occurred at intervals for twelve hours, during which I kept the man 
in the sitting or semi-recumbent posture. Acetate of lead and opium were 
given every second hour in pill, and he used a solution of tartarized antimony 
every half hour, which with fresh tonics and cold acidulated drinks, constituted 
his treatment thus far. The hemorrhage then ceased, and I had no recurrence 
of it. 

On the third day his tongue was thickly coated ; urine scanty and high- 
coloured ; pulse, which previously had fallen to 100, now 130. Continuing the 
antimonial, I gave him a calomel and nitre purge, when his pulse again fell to 
near 100 ; tongue cleaner. 

On examining his chest there was dulness for a palms' breadth around the 
wound of entry, and the same near the angles of the ribs, where the bullet left 
the thorax, with external discolouration. The respiratory murmur was absent 
in the same situation, and there were bloody rales throughout the entire lung. 
He had a short hacking cough and hurried constrained respiration, with dilated 
nostril, and a painfully anxious countenance, especially when the bandage was 
temporarily removed. On the fourth day he was breathing better ; countenance 
was less anxious ; pulse was at 90 ; evacuations were natural : there was slight 
dry cough, and both wounds were suppurating kindly. Percussion and auscul- 
tation gave the same results as before, I now gave him a blue pill morning 
and evening, and a few fowls were foraged out for broth. In a few days, the 
gums being slightly touched with the mercurial, and all active treatment stop- 
ped, I was enabled to remove him to the hospital ship, several days' journey 
distant, where I continued in charge of him. 

The wounds suppurated freely for a month, and then, for the first time at the 
posterior orifice, appeared in the discharge a strip of his shirt, which being car- 
ried in by the bullet, traversed the lung from front to rear. I had him in my 



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Progress of the Medical Sciences. [July 



charge for a fortnight after, at which time the anterior wound (of entry) was 
completely healed ; the posterior one very nearly so. I applied a mixture of 
iodine and mercurial ointment as a discutient, in the neighbourhood of the hepa- 
tized lung, for several days, by which I think the obstruction was in some mea- 
sure removed, and the constriction and sense of pain through the chest alleviated. 
The man was now able to walk about ; general health tolerably good. There 
was a slight hitch remaining in the respiration, some pain of right side, and his 
chest was somewhat hollowed from absorption of tissue in the neighbourhood of 
the bullet track. There was some slight bulging of the intercostals at the lower 
part of the pleura, and dulness corresponding to it, but no evidence of fluid from 
succussion. Pulse was 80 ; countenance, " shot-stricken." 

The man was no doubt ultimately discharged from the service, as unfitted to 
bear the vicissitudes of a " sea soldier's life," but I dare say able all the while 
to supplementalize his means of living and his pension by any light employment 
in civil life. This case is interesting, inasmuch as I see that perforating gunshot 
wounds, through the thickness of the lung, are in most instances recorded as 
fatal. — Diiblin Medical Press, April 9, 1862. 

51. Difficulties in the Treatment of Uinbilical Hernia. — M. Huguier, in a 
discussion in the Surgical Society of Paris, gave a summary of the. causes which, 
in his opinion, render strangulated umbilical hernia and the operation thereon 
specially dangerous. Some of these causes are primary — arising out of the 
anatomy and pathology of the parts ; the others are surgical — attending and 
following the operation. The primary causes are the following : 1. The abdo- 
minal opening, in general circular or oval, narrow, resistant, and with thin edges, 
bruises and almost cuts the parts. 2. The umlDelliform or mushroom-shaped 
arrangement of the protruded parts gives the tumour a narrow pedicle in pro- 
portion to the mass which has escaped. 3. The thinness of the coverings pre- 
disposes to accidents in three ways — by bruising of the parts ; by inflammation 
of the distended and weakened coverings ; and, perhaps (as in an example re- 
lated by Boyer), by their rupture through a fall or blow. Further, this state 
of the integuments render the intestines liable to injury during operation. 4. 
The sac contains little or no serosity. 5. The sac is frequently gangrenous. 6. 
The large size of the tumour, and the adhesions which it contracts, render it 
more frequently irreducible. 7. The vicinity of the strangulation to the perito- 
neal cavity predisposes to visceral and parietal peritonitis ; this circumstance is 
of great importance in a surgical point of view. The surgical or consecutive 
causes of peril are these : 1. In the flrst stage of the operation, there is great 
danger of wounding the herniated parts, in consequence of the thinness of the 
coverings, the frequent absence of fluid from the sac, and the presence of numer- 
ous adhesions of the viscera to each other and to the peritoneum. 2. In the 
majority of cases, it is necessary to reach the intestines, to pass through the epi- 
ploon; which, after being wounded, is returned into the abdomen. 3. The her- 
niated parts may suddenly burst through the incision in the covering. Boyer 
and M. Huguier have both met with instances of this, 4. After the parts are 
denuded and liberated from strangulation it is extremely diflicult, sometimes 
even impossible, to reduce the hernia. 5. The proximity of the incision made 
in releasing the strangulation to the parietal peritoneum necessarily causes this 
to be wounded. In inguinal and crural hernia, the strangulation is at a distance 
from the great peritoneal cavity ; whereas the reverse is the case in umbilical 
hernia. 6. Extension of inflammation from the sac to the peritoneum is more 
rapid and much more unavoidable than in other hernise. 7. The dependent 
position of the hernial opening, when released from strangulation and enlarged, 
favours (as M. Yelpeau has observed) the escape of blood, pus, and decomposed 
fluids into the peritoneum. M. Huguier says that blood is by no means innocu- 
ous ; he has seen violent peritonitis produced by the presence of a small quan- 
tity in the cavity. If an operation is to be performed, he advises that complete 
herniotomy (incision of the coverings, release of the strangulated parts, and 
reduction) be practised only in small, recent umbilical herniae, which have been 
previously reducible. In most other cases, he prefers opening the intestine to 



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253 



releasing, tlie strangulation and reducing the parts. — Brit. Med. Journ., Jan. 25, 
1862, from Gaz. des Hopitaux, Nov. 23, 1861. 

52. JEther and Belladonna in Strangulated Hernia. — Dr. Burkhardt states 
that for many years past he has employed for the reduction of strangulated 
hernia, in conjunction with the taxis, a mixture of one ounce of ether and two 
drachms of tincture of belladonna, which is either dropped upon the hernial 
tumour or applied to it as a lotion. He has seldom found it fail even in cases 
in which the strangulation has long existed. The benefit which results is not a 
consequence of the mere cold produced, which may easily be induced, and in a 
much greater degree, by other means, without the same effect being produced. — 
Med. Times and Gaz., April 19, from Varges' Zeitschrift, vol. xv. No. 1. 

53. Camphorated Cfiloroform as a Local Ancesthetic in Extirpation of the 
Toe Nail. — M. Martenot de Cordoux relates [Bulletin de la SociSte de M6de- 
dne de Besangon) two cases of removal of toe nail, in which pain was entirely 
prevented by the following procedure : — 

The toe was in the first place tightly surrounded at its basis with a ligature, 
and enveloped for twenty minutes in a thick layer of lint impregnated with cam- 
phorated chloroform, and to obviate evaporation, a water-proof cloth was laid 
over all. The fluid used consisted of a solution of four drachms of camphor in 
one ounce of chloroform. 

M. Martenot de Cordoux removed at one sweep of the knife, by Mr. Bauden's 
operation, one-half of the nail and the exuberant flesh ; and although in one case 
this procedure had to be twice repeated, the anaesthesia was so complete that 
no pain whatever was experienced. — Glasgow Medical Journcd, April, 1862. 

54. Congenital Inversion of the Bladder ; Cure. By J. Lowe, M. D. — This 
affection is so rare that it is passed over in silence by most authors of systematic 
works on surgery. The only recorded case which I have met with is that given 
by Mr. Crosse, in the British and Foreign Medical Review (Oct. 1846, p. 319),' 
which is exceedingly interesting as showing the importance of careful diagnosis 
before attempting any operative measures on tumours of the genital parts in 
female children. In this instance, the patient, aged three years, had a tumour, 
to which a surgeon was about to apply a ligature, when Mr, Crosse, who hap- 
pened to be present, fortunately discovered an aperture which he found to be 
the ureter. The operation was of course postponed sine die. By firm pressure 
the inverted bladder was made to repass into its natural position, and conse- 
quently the child was saved from an untimely death. The report goes on to 
say that the prolapse of the bladder did not subsequently return ; and the 
patient grew up to womanhood with no other inconvenience than a constant 
incontinence of urine. . 

The following report of a very similar case may prove worthy of being re- 
corded, more especially as operative interference, which does not appear to 
have been found necessary in Mr. Crosse's case, was here pursued with excellent 
results : — 

M. A. H , aged two years and a half, a fine, healthy, but very irritable 

girl, was admitted into the West Norfolk and Lynn Hospital on the 10th of 
November, 1859. On examination, a vascular-looking tumour, about the size 
of a large Italian walnut, was found projecting between the external labia. When 
the little patient cried, the tumour became more injected, and increased con- 
siderably in size ; at the same time, a gush of urine took place. On closer in- 
spection, the mass was found to be seated at the orifice of the urethra. On 
making a little gentle pressure, the tumour receded under the finger, and pre- 
sently disappeared altogether within the urethra, and the forefinger could be 
readily passed into the bladder. I had, therefore, no difficulty in diagnosing an 
inversion of the bladder. 

From the statement of the mother, it appeared that the child had been subject 



' From the Transactions of the Provincial Medical and Surgical Association, vol. 
xi., 1846. 



254 



Progress of the Medical Sciences. 



[July 



to incontinence of urine from its birth, and that from the time it was two or three 
days old, a small substance had been observed to protrude during a fit of crying 
or straining. Each effort of this kind was followed by a flow of urine, and the 
child's condition from this cause was truly pitiable. The thighs and labia were 
much excoriated, and the latter, as well as being swollen and indurated, were 
covered with numerous pustules. Until the age of two years, the tumour had 
receded as soon as the fit of straining was over ; but latterly it constantly pro- 
truded more or less. 

After considering the various means which might afford a chance of improving 
this distressing condition, I resolved upon making use of the actual cautery, 
which seemed to me best adapted for narrowing the calibre of the urethra, and 
thus preventing the descent of the bladder. Accordingly, after putting the 
patient under the influence of chloroform, and having replaced "the bladder 
within the pelvis, where it was retained by two stout probes, which served to 
keep the canal patent, a female sound, heated to a white heat, was applied to 
the track of the urethra. A small curved catheter with a bulbous extremity, 
which had been previously made by my direction, was then introduced and fast- 
ened in, and the patient put to bed. No constitutional symptoms followed, but 
there was considerable pain in passing urine. 

On the 17th, a small shred of slough separated. Patient can retain four ounces 
of urine when in the recumbent posture. 

Pec. 1st. The catheter on being removed was found coated with a thick de- 
posit of phosphate of lime ; urethral canal perceptibly smaller. 

After the expiration of a month, during which time there was destination 
pretty constantly, with occasional power of retaining several ounces of urine, 
the cautery was again applied as before. The same manifest improvement fol- 
lowed. The child became much more comfortable and cleanly in person. The 
excoriations almost entirely disappeared, and the pustules healed. 

On three subsequent occasions (making five in all) the cautery was repeated 
after long intervals. The urethra became so much diminished as to admit only 
a No. 4 catheter ; urine escaped only when patient cried or strained. 

After having been a patient of the hospital about eleven months, during the 
latter part of which she was an out-patient, coming in at intervals to be operated 
on, she was discharged. I have since learned that she continues well, with not 
the slightest evidence of prolapse, but with some degree of incontinence of urine. 
—Lancet, March 8, 1862. 

55. Tlie Cochin China Ulcer. — M. Pochard, Chirurgien-en Chef of the French 
Navy, describes a form of ulcer which is endemic in certain parts of Cochin 
China, and has prevailed extensively among the French troops in that country. 
Its predisposing causes are the insalubrity of the climate, and the consequent 
anaemia and debility. It is more severe during the rainy season ; age, constitu- 
tion, and race, have no influence on its production. The characters of the ulcer 
are aggravated among the natives by dirt, skin-diseases, weak constitution, and 
the want of treatment. There is no evidence to prove that it is contagious ; but 
rather the contrary. 

The ulcer always commences with a lesion of the skin, never suddenly ; but, 
in debilitated subjects, the most insignificant wound or erosion is sufficient to 
produce it. The lower limbs are always its seat ; it especially attacks the 
ankles, the anterior part of the lower third of the leg, the instep, and the dorsal 
surface of the foot. M. Pochard has never known it to appear on the plantar 
surface. It is generally solitary, but sometimes both legs are affected at the 
same time. The diameter of the ulcer is rarely less than nearly two inches ; but 
sometimes it extends round the legs, and in some very rare cases the whole leg 
has been involved. The form of the ulcer is irregularly angular. The ravages 
of the disease are generally confined to the skin and subcutaneous tissue : in 
severe cases, however, it burrows among the muscles, and produces exfoliation 
and necrosis or caries of the tendons and bones. In this condition, amputation 
is the only resource, but is rarely successful. 

The progress of the disease is rapid. Under the influence of the predisposing 
causes already mentioned, an apparently insignificant lesion b'ecomes painful ; it 



1862.] 



Ophtlialmology. 



255 



is surrounded with a dark red areola, and in a few days there is a large ulcer of 
gangrenous aspect, from which escapes an extremely fetid ichor. The inflam- 
matory period is accompanied by pains which contrast strongly with the com- 
plete insensibility which prevails at a later period. 

After a variable time, the ulcer ceases to increase ; it becomes clean ; an. 
eschar, comprising generally the entire thickness of the skin, is detached, leaving 
a sanious surface, which is soon again covered by a pultaceous layer. In the 
most severe cases, the disease runs its course, increasing in surface as well as in 
depth; and finally produces death, unless amputation be performed. In the 
more favourable cases, after numerous alternations of amelioration and of re- 
lapses, cicatrization is established; and, if the patient can leave the country and 
regain his strength, the cure is permanent. In other cases, again, the disease 
becomes chronic ; and it is in this form alone that M. Rochard has had personal 
opportunities of observing its character. In the patients under his care at the 
Brest Hospital, the ulcers presented a depressed, uneven base, traversed by 
deep red longitudinal streaks, consisting of small anastomosing bloodvessels, 
having between them yellowish lines of a pultaceous aspect. The edges of the 
ulcer are callous, as if cut perpendicularly, but irregular; the surrounding skin 
is wrinkled, the folds radiating towards the centre of the ulcer. There is com- 
plete anaesthesia, not only in the parts immediately affected, but also in the sur- 
rounding parts, and sometimes even in the whole limb below the ulcer. In one 
case, the ulcer was seated below the external ankle ; and both the dorsal and 
the plantar surfaces of the foot were insensible ; no sensation was produced by 
the application of the strongest caustics or of red hot iron. The subjacent 
muscles are also sometimes paralyzed; this happened in the case just mentioned. 
No treatment seems successful. Cauterization, with tonics and good diet, have 
appeared at first to produce the most promising results : but as a rule, the dis- 
ease returns as soon as the patient begins to walk. In one case, where the ulcer 
was seated on the dorsum of the foot, M, Rochard obtained a successful result 
by excising the ulcer, and performing partial excision of the foot. — Dublin Med. 
Press, May 21, 1862, from Gaz. des Hop. 



\ 

OPHTHALMOLOGY. 

56. Frequent Evacuation of the Aqueous Humour as a, Means of Causing 
tTie Absorption of Cataract, — Prof. Sperino, of Turin, recommends the repeated 
evacuation of the aqueous humour for the purpose of causing the absorption of 
opacities of the crystalline lens, and asserts that it has proved successful in 
various cases under his care at the hospital at Turin. He remarks, "The prac- 
tical studies I have been continuing for several years on the new method of 
treatment in various disorders of the ocular bulb, have induced me to have 
recourse to it also in the case of persons labouring under cataract. The facts 
observed by me up to this day at the Ophthalmic Hospital, at the House of 
Public Assistance, and within the range of my own private practice, have proved 
to me that the evacuation of the aqueous humour effected daily, or even every 
second or third day, will gradually restore transparency to the crystalline lens, 
and consequently remove the obstacle which impedes vision. It is curious to 
observe how the opaque materials of the crystalline lens are gradually replaced 
by transparent ones, owing to the frequent removal of the aqueous humour, and 
it is not less consolatory to hear the patients daily congratulate themselves on 
the gradual recovery of their eyesight. At present I merely announce my dis- 
covery, but I shall soon publish my clinical observations, which are daily increas- 
ing in number, and I shall then describe the experiments by which I have been 
guided, the method of cure, its effects in the various kinds of cataract, and dif- 
ferent degrees of opacity of the crystalline lens ; in a word, all I daily learn from 
the attentive observation of facts. Let me, however, remark, that, supposing in 
certain cases the mere evacuation of the aqueous humour were not found siiffi- 



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Progress of the Medical Sciences. 



[July 



cient to obtain a perfect cure, this observation would still have the effect of 
restoring the functions of the inner vascular system of the eye, and would thus 
at all events prepare the patient by placing him in the most favourable condition 
for the operation of the cataract." 

Dr. J. G. HiLDiGE has experimented with this method, and has given the 
results in a recent No. (May 21, 1862) of the Dublin Medical Press. 

"Having," says Dr. H., "some misgivings as to whether a frequently repeated 
paracentesis of the cornea might not cause a too great irritation of the ocular 
bulb, I selected an eye that was not only cataractous but also partially amau- 
rotic. The patient, Mrs. 0., aet. 45, residing in Eedmond's-hill, is affected with 
soft cataract in both eyes. That in the right eye is perfectly formed ; the inter- 
nal portion of the retina is, however, insensible to light, so that when a candle 
is held in the external part of the field of vision, at the distance of a few inches 
from the eye, it is not perceived ; the other tissues of the eyeball are tolerably 
healthy. The vision of the right eye is still good enough to permit her to go 
about alone, and to see large objects. General health pretty good. I punctured 
the left eye with a broad-bladed needle at the external junction of the cornea 
with the sclerotic, and allowed the aqueous humour to escape. On the following 
day I repeated the puncture, introducing the needle at the inferior part of the 
cornea, and so varying the seat of the puncture each time, as to cause as little 
irritation to the eyeball as possible. 

"The eye was slightly inflamed on the third day, the pupil contracted, and 
other symptoms of irritation present, so that I was obliged to allow two or three 
days to intervene before resuming the treatment. It were needless to describe 
the effect of each paracentesis on the eyeball ; let it suffice to say that I repeated 
the operation eleven times, allowing one. two, and three days to intervene, ac- 
cording to the amount of irritation present, and the following was the result of 
the treatment : The cornea had become slightly conical, so that the anterior 
chamber was much deeper than in the normal condition ; the iris was of a much 
deeper tinge than that of the other eye ; pupil contracted, and small dots of pig- 
ment, detached in all probability from the posterior part of the iris, were depo- 
sited on the anterior capsule of the lens. On dilating the pupil with atropine, 
one side of it was observed to be adherent, and masses of pigment were attached 
all round its circumference, protruding as it were from the posterior surface of 
the iris. The lens was in every respect in precisely the same condition as it was 
previous to the commencement of the treatment, presenting the same degree of 
opacity without the slightest symptom of absorption having taken place in any 
portion of it. The effect of the frequent paracentesis was certainly to produce 
hypersecretion of the aqueous humour ; this, however, instead of causing absorp- 
tion of the cataract, produced a more or less staphylomatous condition of the 
cornea, the anterior chamber not being capacious enough to contain the quantity 
of aqueous humour secreted. This result has not justified me in experimenting 
on a second case, the eye having been decidedly damaged by the treatment. As 
Professor Sperino has, however, promised to publish shortly the notes of his 
cases, we shall then be better able to form an opinion of the question than we 
are at present." 

[Though we are far from hopeful of the success of this mode of treatment of 
cataract, it must be confessed that the evacuation of the aqueous humour is likely 
to affect the nutrition of the lens, as would also its replacement by injecting 
fluids of different densities. The experiments of Drs. Mitchell and Richardson 
seem to open a wide field for investigation in regard to this subject.] 

57. He:reditary Amaurosis. — Mr. Sedgwick related to the Harveian Society 
of London the case of a gentleman whose brother became blind from amaurosis 
in both eyes, between the age of 55 and 60 years, had a family of ten children, 
consisting of seven sons and three daughters. The first son, who is still living, 
became amaurotic in both eyes when about 56 years old ; the fifth son, who died 
from paralysis, became amaurotic in both eyes at the age of 48 years ; the sixth 
son, still living, became amaurotic in the left eye at the age of 46 years ; and 
the seventh son, now dead, became amaurotic in both eyes when about 42 years 
old. Of the other three sons, the second, who died from paralysis at the age of 



1862.] 



Ophthalmology. 



257 



56 years, the third aged 60 years, who is still living and is partly paralyzed, 
and the fourth aged 56 years, also living, have no occurrence of the disease. 
"Whilst the three daughters, who are all living — the eldest of whom is now 63 
years of age, and is the second child in the family, and the youngest about 38 
years of age, who is also the youngest child in the family — have been quite free 
from the disease. Mr. Sedgwick remarked that the above case would serve to 
illustrate two points of interest in connection with the hereditary development 
of disease, viz., the sexual limitation of the disease to the males only in the 
family, all the females being exempt, and the retrogressively earlier develop- 
ment of it in each succeeding member of the family affected ; so that, whilst 
the eldest of the four brothers became amaurotic at about the same age as his 
paternal uncle, the three younger became so at an earlier age in each case than 
the preceding, the sequence being 56, 48, 46, and 42. — Med. Times and Gaz., 
March 22, 1862. 

58. Amaurosis cured hy Evacuation of the Aqueous Humour. — An interesting 
case of amaurosis was recently observed in the ophthalmological clinique of the 
University of Munich. A country girl, aged 18, while at her work, suddenly 
felt that her sight became diminished. All objects appeared to her as in a haze, 
and on the next day she was scarcely able to distinguish anything. The day 
after she went to church, but had to be carried home, as she had then lost her 
sight altogether. Leeches, ice, and purgatives were used, but without success ; 
and six days after the vision had first become impaired the patient came to 
Munich, and was received into the University Hospital. The pupils were im- 
mensely dilated, and did not contract even if very strong light was used. By 
means of the ophthalmoscope it was then observed that the arteria centralis 
retinfB was unusually narrow, and its ramifications did not contain any blood. 
The vein appeared very dark and narrow, but not to the same degree as the 
artery ; on slightly pressing the eyeball no pulsation could be felt. The choro- 
idea was normal, and its vessels were clearly visible. Otherwise there were no 
traces of oligsemia; on the contrary, the complexion was ruddy, the pulse full, 
and the sounds of the heart were normal. The patient complained of noises in 
the ear, and of heat in the head. At the time when she had become blind, she 
had just had her courses, but they had been more scanty and shorter than usual. 
The treatment in the hospital consisted of leeches to the temples ; foot-baths, 
and sinapisms to the thighs. On the second day, calomel, in refracta dosi, was 
added to this medication. On the third day the patient said that if a hand was 
passed before her face she could see it with the left eye ; while the right con- 
tinued to be completely amaurotic. After nineteen days there was no further 
improvement ; on the contrary, the ophthalmoscope showed that the arteria 
centralis retinae had become still narrower than it had been at first, and that the 
chief branch of the same artery on the right side did not contain any blood. It 
was, therefore, feared that the retina might become atrophied in consequence of 
anaemia of its vessels ; and paracentesis of the anterior chamber of the right eye 
was then performed by the surgeon. Mr. Rothmund, with the view of inducing 
congestion by the vacuum thus caused in the eye. Immediately after the opera- 
tion the pupil appeared contracted, as is always the case after paracentesis ; but 
on the next day the patient was able, with the eye upon which the operation had 
been performed, to count the fingers held at a distance of six inches from the 
eye ; and on the fourth day after the operation she could see the fingers at a 
distance of one foot and a half. The pupil had, by that time, also again become 
sensitive to light and dark. As the left eye did not improve in the meantime, 
it was operated upon in the same manner. The vision then likewise improved 
in this eye, and on the ninth day the patient was again able to read large type. 
She was discharged cured, as after some time she could read the very smallest 
type, and the ophthalmoscopic examination showed that both retinae were per- 
fectly normal. A similar case has been published by Dr. A. Yon Uraefe, who 
by excising a piece of the iris of the right, and making the paracentesis of the 
anterior chamber of the left eye, also completely cured his patient. — Med. Times 
and Gaz., April 12, 1862. 

No. LXXXYIL— July 1862. IT 



258 



Progress of the Medical Sciences. [July 



59. Retinitis LeuJccemica. — Dr. Liebretch, one of tLe most distinguished 
pupils of Prof. A. Yon Graefe, and of whose researches on retinitis pigmentosa 
in the offspring of marriages of consanguinity I gave you an account in a former 
letter, has recently discovered that in patients suffering from leukaemia, a pecu- 
liar form of retinitis occurs, which has just as characteristic features as that 
form of retinitis which is observed in cases of syphilis and Bright's disease. 
Idiopathic retinitis is, according to Dr. Liebreich, exceedingly rare, and it is a 
curious fact that,, while idiopathic diseases of the choroidea are much more fre- 
quent than those due to constitutional distempers, the disorders of the retina 
are either of local origin, and consequent upon wounds or diseases of the adja- 
cent choroidea, or produced by disturbances of general circulation, as in cases 
of heart disease and Bright's disease, and by diseases of the blood, such as 
syphilis and leukaemia. 

In retinitis consequent upon Bright's disease, the ophthalmoscopic examina- 
tion shows that the optic nerve is encircled by an opaque, whitish zone ; between 
the nerve and the zone a grayish-looking part of the retina is visible, which is 
scarcely to be distinguished from the papilla, which latter has also a grayish 
appearance. Outside of the opaque zone just mentioned, small and fine points 
may be generally noticed, which are due to extravasation, and are chiefly fre- 
quent in the neighbourhood of the macula lutea. In retinitis syphilitica, on the 
contrary, the opacity extends from the papilla along the course of the large blood- 
vessels, and towards the periphery, where it gradually ceases. Extravasations, 
which are very frequent in retinitis coupled with Bright's disease, are exceed- 
ingly rare in syphilitic retinitis ; and if present, they are totally different from 
those observed in the former affection. In leukgemic retinitis it is especially 
the colour of the bloodvessels and of the extravasated blood, which presents 
striking peculiarities. The blood and the veins, which are very much dilated, 
are of a pale pink ; the arteries are contracted, and of a bright orange colour, 
and the vessels of the choroidea of a pale yellow. — lied. Times and Gaz., April 
12, 1862. 

60. Embolism of the Arteria Centralis Retince. — The chief symptoms of this 
disease, of which Dr. Liebreich has hitherto observed six cases, are the follow- 
ing : The patient suddenly perceives dimness of vision in one eye, as if a thick 
cloud was passing. He then generally closes the other eye, and finds that, after 
a few minutes, the whole field becomes so obscured that not even the faintest 
perception of light is possible. This condition either remains stationary, or a 
slight perception of light gradually returns in a limited part of the field. The 
ophthalmoscopic examination of the eye shows that the circulation in all or 
several of the arteries of the retina has altogether ceased ; the vessels are thin, 
and partly filled with thick and dark coagula. The central artery of the retina 
is quite empty, and the veins are also much thinner. A few days after the com- 
mencement of the illness, an opacity of part of the papilla, macula lutea, and its 
neighbourhood, is visible ; and between the macula and the optic nerve, small 
red points are to be perceived, which are owing to extravasated blood. Although 
there is no blood in the arteries, the venous circulation is not entirely stopped, 
but it is retarded and irregular. After some time, however, this is, in a measure, 
re-established ; while the arteries either remain empty, or again contain a little 
blood. The opacities in the macula lutea undergo various changes as to colour, 
size, etc. ; and, finally, the optic nerve is completely atrophied. 

In five out of six cases of this affection there was heart disease. In one case 
considerable insufiiciency of the aortic valves, with consecutive hypertrophy and 
dilatation of the left ventricle, was found to exist. The compensation afforded 
for the valvular disease by the hypertrophied muscular substance of the heart 
was so complete that the patient was not even aware of having heart disease, 
and which was only discovered by Dr. Liebreich after, by the embolism of the 
arteria centralis retinae, he was led to make the physical examination of the 
chest. In the same patient, an embolus was soijie time afterwards lodged in the 
brain, and produced hemiplegia. — Ibid. 



1862.] 



Ophthalmology. 



259 



61. Loss of an Eye from the Bite of a Leech. — Prof. Yox Geaefe relates, in 
the second part of the seventli volume of the Archiv fiir Opldlialmologie, the 
case of a delicate little girl, of five years of age, who, some days before he saw 
her, had on account of headache been ordered a leech to the right temple. The 
eye itself before this application had been quite healthy, and its vision perfect. 
He found the interior chamber filled with blood ; the lower half of the conjunc- 
tival sac, including the edge of the cornea, ecchymosed ; in the lower half of the 
cornea, nearly a line from the limbus conjunctivge, a wound, the edges of which 
and neighbourhood were somewhat swollen, and presented a grayish opacity. 
The form of the wound, on close inspection, left no doubt that it was the result 
of the bite of a leech. It came out, that, in making the application ordered, the 
leech had slipped away, had crept into the eye, and there, under considerable 
pain to the child, had accomplished its work of destruction. Unfortunately, 
perception of light was completely lost, apparently in consequence of total sepa- 
ration of the retina by hemorrhagy. 

As the Professor had never in such a case of haemophthalmos, from whatever 
cause arising, observed a restoration of sight when once quantitative perception 
of light had for more than some hours been lost, so here he gave the most un- 
favourable prognosis. He saw the child a few times afterwards. The blood in 
the anterior chamber had partly disappeared, the eyeball was already boggy, and 
he had no doubt that phthisis oculi had commenced. 

The Professor observes, that the case, while on the one hand it serves as a 
warning against the careless application of leeches in the vicinity of the eye, is 
interesting in another respect, that the bite was not within the extent of the 
conjunctiva, but nearly a line from it, and in a part which in the normal state is 
deemed destitute of vessels. How far the leech filled itself with blood, and how 
long it sucked, he could not determine. The conjunctival ecchymosis termi- 
nated abruptly at the limbus conjunctivae, from whence, in the direction of the 
wound, there was only a non-vascular infiltration. It is also possible, he ob- 
serves, that no blood escaped by the wound, but that the strong suction alone 
used the intra-ocular and extra-ocular hemorrhagy .-^ 6rZas^ott/ Medical Journal, 
April, 1862. 

62. Piece of Stone Imhedded for Seven Months in the Cornea. — Dr. Wm. 
HuTCHiNsox records [Dublin Medical Press, March 26, 1862) the following 
example of this : — 

On the 26th of July, 1861, a man, set. 56, presented himself " suffering under 
intense pain, and covering his left eye with his hand, on removing which I at 
first sight thought I saw the iris protruding through the cornea, but changed 
my opinion at once seeing it was exactly in the centre of the cornea. I asked 
him his history of his case, and he told me he had been breaking stones for the 
road in the week before Christmas, 1860, just seven months, and he thought a 
piece of the stone (which I inclose herewith) struck him in the eye, and he had 
intense pain, &c. Strange to say he was treated for the seven months as a case 
of procidentia iridis, and was suffering the same pain all that time. I got a 
cataract forceps, and brought out the little piece of stone without using any 
force-. The aqueous humour followed in a jet. The poor man was greatly 
delighted at the cessation of the pain. The cornea in this case had wonderful 
endurance, for it remained in a perfectly sound state, notwithstanding the long 
continuance of the hard body imbedded in its substance exactly opposite the 
pupil for seven months. He was discharged on the 5th of September, seeing 
nearly as well as ever. 

63. Rectification of Divergent Strabismus by the Methodical Use of Pris- 
matic Glasses. — An eye affected with squinting, as our readers are aware, sel- 
dom takes any share in binocular vision ; when it contributes to the function, it 
is but in a very limited degree, and only provided the divergency is moderate. 
In general the deviating eye has separate sensations, and the healthy eye alone 
is used by the patient. 

If, under these circumstances, the image of objects seen by the healthy eye 
be placed before the inert organ with the assistance of a prismatic glass of an 



260 



Progress of the Medical Sciences, 



[July 



angle proportionate to the degree of the squint, both eyes will be in possession 
of two similar images, at the intersection of the ocular axes, and coalescence of 
the two figures, and subsequent visual perception of a single object will be the 
result. 

Both eyes are thus artificially brought into simultaneous action; but for 
restoration of the regularity of the ocular axis nothing yet has been done. Now, 
if instead of the prism above described, the angle of which (at the summit) would 
be about double the angle of deviation of the eye, a prism is used of a slightly 
smaller angle, inferior, for instance, by two or three degrees to that of the devia- 
tion, each organ still receives the impression of the object, but not precisely at 
the same focus. The images are seen double, but in close approximation, crossed 
if the strabismus is divergent, superposed if internal. 

In accordance with Wheatstone's law on binocular perspective, the tendency 
of the patient is to exert himself continually to neutralize the diplopia, and as, 
on account of the angle of the prism, the images are very close to each other, 
the instinctive effort overcomes their separation ; they soon blend, and as this 
result is due to the agency of the muscles of the divergent eye, a part, however 
small, of the deviation is thus corrected. 

When the diseased eye has, by uninterrupted exercise of a certain duration, 
say about a week, gained a little in the right direction, another prism of a smaller 
angle is used, and the eye is for another week compelled to fresh exertion, and 
after a short time binocular association is gradually restored. 

On these principles. Dr. Giraud-Teulon, formerly a pupil of the Polytechnic 
School, and the author of a recent treatise on the physiology and functional 
pathology of binocular vision, rests his treatment of squinting in a case recorded 
in the Gazette Aledicale. 

On the 24th of April of the present year, a young lady, aged 17, was presented 
by Mr. Demarquay to M. Giraud-Teulon, as an instance of strabismus resulting 
more probably from functional than from anatominal disease. The right eye, in 
which existed some slight corneal opacity, was considerably divergent ; the outer 
edge of the cornea being in contact with the external canthus in more than 20 
degrees' deviation. No muscular retraction was present, but some slight spas- 
modic movements were observed, and the eyeball moved freely from one side of 
the orbit to the other. In the healthy eye the visual function was perfect, but 
the other was decidedly myopic. Thus, in order to read with this eye alone, the 
patient was obliged to use a biconcave glass. No. 14;' and to read without effort, 
with both eyes together, the divergent eye required the assistance of a prism 
(with its summit turned outwards) of 18 or 20 degrees. 

From these data, M. Giraud-Teulon concluded that the great disparity in 
vision between the two organs was the cause of squinting, and ordered the pa- 
tient to wear glasses constructed as follows : Before the left eye a plane glass, 
No. 0, and before the right a biconcave glass. No, 14, in contact by its external 
surface with a prism measuring at its summit (turned outward) 14 degrees. 

The treatment was instituted May 4th. 

Every eight or ten days the angle of the prism was reduced by about two 
degrees, and the axis of the eye restored in a corresponding amount to its natural 
direction. A singular circumstance was then observed: in proportion as the 
divergency decreased, and as binocular vision was accomplished with weaker 
glasses, the patient complained that the sight of the sound eye was becoming 
shorter. M, Giraud-Teulon then measured the range of vision in this eye, used 
singly, and found it what it was at the beginning of the treatment ; he again 
measured it, both eyes acting together, and to his surprise discovered that the 
originally healthy eye had become myopic in binocular association.' He then 
resumed the treatment, substituting for the plane glass of the left eye a bicon- 
cave glass, No. 14, as on the other side, and after two months' perseverance 
binocular vision was restored, natural as to direction, but myopic on both sides. 
Towards the 15th of July the patient was even compelled to exchange her 
glasses for biconcave spectacles. No. 12, and all further artificial rectification 
by means of prisms was abandoned. All that could be expected in this case 



French scale. 



1862.] 



Midwifery. 



261 



was thus attained, and the patient must persevere in the use of the common 
lenses used by myopic persons, with the assistance of which she is enabled to 
perform all the duties of life. — Glasgow Medical Journal, April, 1862, from 
Journal of Practical Medicine. 

64. Hemorrhage into the Anterior Chamber of the Eye, supplementary to the 
Menstrual Flux. — M. Guepin relates the curious case of a young lady, aged 18, 
of good constitution, with a delicate skin, and somewhat lax tissues who com- 
menced menstruating three years since. The menses returned every thirty or 
thirty-two days with tolerable regularity, lasting sometimes but one day, and at 
others five or six, and generally three days, the quantity of fluid lost thus vary- 
ing greatly. She has always found that on the cessation of the menstrual flux 
there has been a supplemental epistaxis, this being more or less abundant in 
inverse proportion to the quantity of menstrual fluid lost. On one occasion, 
however, the epistaxis did not appear, and then a sudden effusion of blood into 
the anterior chamber took place, which brought her under the author's notice, 
the menstrual discharge on this occasion only having lasted two hours. The 
lower part of the anterior chamber was filled with blood, which rode over the 
free edge of the iris. The author believes the case to be unique, the one nearest 
approaching to it being an example of hemorrhage into the vitreous humour in 
a subject of amenorrhoea reported in the thirty-fifth volume of the Annales. — 
Med. Times and Gaz., March 29, 1862, from Annales d' Oculistique, Yol. 
XLYI. 



MIDWIFEEY. 

65. Mechanism of Labour. — Dr. Halahan read before the Dublin Obstet- 
rical Society the following paper on this subject : — 

" The position in which the head of the foetus enters and passes through the 
pelvic cavity during labour, has long occupied the attention of many midwifery 
practitioners, and given rise to a great deal of discussion. But I am convinced 
every practical man must allow that the description given by Naegelfe, is the 
accurate, and also the only correct one ; and that the practitioner cannot, with 
any degree of truth, contradict the statement that the head, at the full term of 
gestation, enters the pelvis in the four positions described by him. I shall here 
briefly enumerate them, the first has the anterior fontanelle directed to the right 
sacro-iliac synchondrosis, and the posterior one towards the left foramen ovale ; 
the second, is where the anterior fontanelle is, to the left sacro-iliac synchon- 
drosis, the posterior one to the right acetabulum; the third is the reverse of the 
first, and the fourth of the second. 

"I am equally certain that those who pursue the study further, will agree with 
me in saying, that although the head enters the brim in the before-named four 
positions, yet, at the commencement of labour, when the os uteri is barely be- 
ginning its dilatation, the anterior fontanalle is always directed towards either 
acetabulum or presenting in the third or fourth positions of Naegel^. That the 
fourth changes, at the beginning of labour, into the first ; and the third does 
not change into the second until the head is distending the perineum ; that this 
is the general course, any other being an exception. 

"That to diagnose the position in the first stage of labour, is one of the diffi- 
culties that the accoucheur has to overcome, I am fully aware of. Nothing but 
constant attention, very extensive practice, together with a delicate touch, will, 
with any degree of certainty, conquer the obstacles, and make him master of this 
part of his profession ; for, although in theory it seems very easy indeed to be 
able to diagnose positions, or to say which fontanelle presents at either aceta- 
bulum, we find, in practice, it is one of the most difficult points to be perfectly 
satisfied about, particularly when the head is high up, the membranes entire, and 
the OS uteri not more dilated than to the circumference of a shilling. 

"If, then, it is a fact that at the commencement of labour the face is always 



262 



Progress of the Medical Sciences. 



[July 



directed towards the pubes (and I have taken the greatest care and trouble to 
be perfectly certain, and have fully satisfied myself that it is so, not by the mere 
examination of a few ordinary cases, but by the most careful and constant inves- 
tigation of some thousands of patients which I had the opportunity of watching 
from the commencement of labour until the completion of the second stage), 
there arises the question, how is it we so seldom find the head in the fourth 
position when entering the brim, or even in that position when the os uteri is 
half dilated, but on the contrary, generally discover it in the first? Whereas, in 
the third, it is the exception for the change to the second to take place until at 
the termination of the second stage. The simple answer is, that when the pos- 
terior fontanelle is on a lower level than the anterior, the change takes place 
immediately after the accession of labour, or, in other words, when the chin be- 
comes depressed on the chest, or flexion of the head occurs early, which is the 
case in the presentation of the head in the fourth position. But in the third, we 
generally find the anterior one a little lower, or on a level with the posterior, the 
head being neither flexed nor extended, which prevents the change taking place 
until the posterior one becomes the low^er. This seemingly slight difference in 
the two makes a very great one in the effect of the uterine action in its effbrts 
to expel the head, and make the change which I shall now try briefly to explain. 

" I presume all will allow that the pain or force pf the uterus takes its course 
in the axis of the pelvis, and that the entire power may be directed effectually, 
and with as little loss as possible, it is necessary that the occiput should move 
in the same axis. This is the case in the first and second positions of Naegele ; 
consequently, if the head enters the brim in either of these positions, we should 
expect that labour will proceed favourably. If we examirre a patient at the 
commencement of labour and find the head presenting in the fourth position, the 
posterior fontanelle will generally be the lower or most easily reached by the 
finger, the anterior one being very high up, and felt with difficulty. This admits 
of the uterine force having full power on the head, and the change taking place 
at once. But when the anterior fontanelle is on a level with, or a little lower 
than the posterior one, the greater part of the uterine force is lost, being divided 
between the occiput and sinciput. This can only be understood by remembering 
the direction the uterine force takes, as well as the part of the head it has most 
power on, as we will there see that when the forehead is the lower part, the pain 
has not its full effect on the head, but that there is a loss of power. This is the 
case in the third position, which I think clearly shows the reason that the head 
enters the pelvis in the second position so rarely. Again, if we find the anterior 
fontanelle presenting, in fact, midway between the sacrum and pubes, in the 
third or fourth position, we may naturally expect that the labour will be rather 
protracted, and the second stage very much prolonged, for the head will, with 
very few exceptions, be expelled, face to pubes. 

"It may very reasonably be asked, is there any practical use in being able to 
diagnose in what position the child's head is presenting? Certainly there is, the 
greatest. I shall merely mention two instances. In applying the forceps, we 
always intend and wish to place the pubic blade over the ear, which will be felt 
a little to the right or left of the pubes. Supposing, then, you have the instru- 
ment correctly placed, is it not of very great importance to know which ear is 
towards the pubes, as in the first and third positions, we have the ear in the 
right half of the pelvis ; but if, not knowing the head is in the third, we try to 
rotate as if it were in the first, we bring it out, face to pubes, which is not so 
favourable as if we had changed it into the second position, the occiput not 
adapting itself to the hollow of the sacrum in the same manner in which the face 
does ? Again, if version is to be performed in a head presentation, is it not of 
the utmost importance to ascertain whether the feet are lying towards the abdo- 
men or back of the mother, whereby we may know which hand to use in perform- 
ing the operation, and this fact can only be ascertained by an accurate knowledge 
of the position? 

"I have put in a tabular form five hundred cases, in which the head has en- 
tered the pelvis, showing the relative frequency of the four positions of Naegele, 
taken indiscriminately from the beginning of this year. It will be seen that the 
first position is the most frequent of all, being 61 per cent. ; the third next, being 



1862.] 



Midwifery, 



263 



31.60 per cent.; the fourth next, being; 6.40 per cent., and the second least of 
all, being 1 per cent. That the third changed to the second in every four cases 
out of five, or nearly so, the proportion being 79.75 that changed, and 20.25 
expelled face to pubes. The fourth changed into the first in 84.37 per cent., 
and continued as it entered the pelvis in 15.62 per cent. 



The Ascertained Positions in 500 Cases, 1861. 



POSITIONS OF NAEGELE. 




1st 


2d 


.3d 


Primary 

3d 
changed 
to 2d. 


Total, 
3d 
Position 


4th 


Primary 

4th 
changed 
to 1st 


Total, 
4th 
Position 


Total in 500 cases . 
Percentage . , . 


305 
61 


5 
1 


32 
6.40 


126 
25.20 


158 
31.60 


5 
1 


27 
5.40 


32 
6.40 



" Of the 158 cases in the third position at the commencement of labour, 126, 
or 79.75 per cent, changed to the second; and of the 32 cases in the fourth, 27, 
or 84.37 per cent, changed to the first in the progress of the labour." — Dublin 
Quarterly Journ. Med. Sc., May, 1862. 



66. Induction of Premature Labour in Cases of Constitutional Affections. — 
Dr. Keiller, at the meeting of the Edinburgh Obstetrical Society (February 
21, 1861), remarked that cases occasionally occurred where pregnancy was asso- 
ciated with various constitutional diseases in such a way as to render it incum- 
bent on the practitioner to induce premature labour, with the view either of 
saving the patient's life or of mitigating her sufiferings. He wished to bring 
before the society the history of some cases of this kind, which had recently 
come under his own observation, and in which he had had some difficulty in 
deciding as to the propriety of the operation. 

1. Double Bronchitis. — He had lately had a case of acute double bronchitis 
under his care in the hospital, where the difficulty of breathing was so great that 
the patient sometimes appeared in danger of death from suffocation ; so that, on 
more than one occasion, the officers had been summoned from the surgical de- 
partment under the idea that it might be necessary to have recourse to trache- 
otomy. As the dyspnoea was greatly increased in consequence of the tumid 
condition of the abdomen, premature labour was induced, greatly to the advan- 
tage of the patient, who felt speedy relief, and who soon afterwards recovered 
completely. The child, however, had not been quite viable. 

2. Phthisis. — The history of the next patient, whom he had had under his 
care in the Infirmary, he would give as it had been drawn up by his clinical 
assistant : — 

"-M. D., set. 36, was admitted into Ward XIII, on the 24th September, 1860. 
She was married, and had had eight children. On admission, she was suffering 
from phthisis ; and on examination the left lung was found to be very much dis- 
eased. At this time she said she had not menstruated for four months. The 
uterine bruit could be detected, but not the foetal heart — a few weeks after ad- 
mission, however, it could be distinctly heard. During the next three months 
the disease of lungs advanced rapidly ; the enlarging uterus, gradually encroach- 
ing on the chest, caused severe attacks of dyspnoea, and she often started from 
her sleep with a sensation of sufi'ocation, which was generally relieved when she 
assumed the sitting posture. 

" Qth January. — She says she is now at the eighth month of utero-gestation. 
Dr. Keiller thought there was a chance of saving the life of the child by inducing 
premature labour, and thereby at the same time freeing her from the frequent 
attacks of dyspnoea. 

"Labour in this case was very easily induced. At 9 P. M. an examination 



264 



Progress of the Medical Sciences. 



[July 



was made, and as the os and cervix uteri were soft and dilatable, one finger was 
passed through the os with comparative ease, and the membranes separated to 
a small extent around it. At 11.30 P.M. she had had a few pains. Examined 
again and found the os dilated so much that two fingers could now be passed 
into it, and the membranes separated still further. 

" At 6 o'clock next morning the os was fully dilated, and a large bag of 
membranes protruding. As the right shoulder was the presenting part, turning 
was practised and the child brought away alive. The placenta was expelled 
soon after the child, and the uterus contracted pretty well. Little hemorrhage 
occurred after the expulsion of the placenta. The child was born alive, but was 
small and weakly. 

"The patient's breathing was very much relieved during the next fortnight; 
but, about three and a half weeks after delivery, she died completely exhausted 
by the disease of the lung." 

3. Cardiac Disease. — He had at present under his care another patient, who 
was pregnant for the first time, and was of a very delicate constitution. She 
suffered from enlargement of the heart ; and although there was no distinct 
physical signs of any affection of the lungs, yet her case was a very anxious 
one, as was a member of a very phthisical family, and had herself had some 
haemoptysis a short time before. He (Dr. Keiller) did not think it would be 
necessary in this case to induce premature labour, but thought it extremely 
probable that it might be found necessary to apply instruments early to hasten 
labour when it supervened. 

4. Cerebral Disease. — Another patient, about seven months pregnant, whose 
case he thought worthy of mention, had been for some time in the Infirmary 
under the care of his colleague. Dr. W. T. Gairdner, who regarded the case as 
one of general paralysis. She had become very much reduced in strength, and 
had been sent into his (Dr. Keiller's) ward with the view of having premature 
labour induced. She is the mother of seven children ; suffered during her last 
two confinements from puerperal mania of short duration, and about six months 
ago was observed to suffer from loss of memory and general debility. The 
patient was unable to give much account of herself; and the facts just stated 
had been obtained from her husband, who had reminded Dr. Keiller that he had 
seen the patient, about eight years ago, on the occasion of one of her confine- 
ments, when she was greatly exhausted by a flooding, from which, however, she 
had slowly recovered. He (Dr. Keiller) believed the patient to be the subject 
of chronic cerebral disease, and although she had been several weeks under his 
care, he had not deemed it necessary to have recourse to the induction of pre- 
mature labour, because there seemed every probability that she would be able 
to carry the child to the full time, and because, as yet, the child was hardly 
viable. There was this peculiarity in connection with the case, that the abdo- 
minal and uterine walls were so thin and lax that the foetus could easily be moved 
about in the interior of the uterus by external palpation. The following were 
the notes of the case as recorded by his assistant : — 

" S. C, set. 38, married. Admitted into Dr. Gairdner's ward, December 
13, 1860, suffering from amentia and debility. She is the mother of seven 
children. During her last two confinements she suffered from symptoms of 
puerperal mania, but in a few weeks after each confinement she recovered 
completely. About six months ago she was observed to suffer from loss of 
memory and debility, and she gradually fell into the state she was in on admis- 
sion to Ward XV. 

"After a residence in Ward XY. of two months, she was rapidly losing 
strength, and she was sent to Ward XIII., under Dr. Keiller's charge, in order 
that premature labour should be induced to save the child. 

" As Dr. Keiller, however, did not think the time of utero-gestation far enough 
advanced, and as she improved in general health, the induction of premature 
labour was deferred." 

5. Fatal Vomiting. — Finally, he wished to mention, in connection with these 
cases, the case of a woman who had had several children previously, and had 
never suffered from any abnormal sickness or other morbid symptoms during 
her pregnancies, but who had died, about the third or fourth month of her next 



1862.] 



Midwifery. 



265 



pregnancy, of excessive vomiting. In this case he (Dr. Keiller) regretted that 
abortion had not been induced, as, on post-mortem examination, there was no 
evidence of any other cause for the vomiting except the pregnancy ; and if the 
uterus had been made to discharge its contents, the secondary and fatal symp- 
tom might probably have been relieved. — Edinh. Med. Journ., March, 1862. 

67. Internal Surface of the Uterus after Delivery, — Dr. J. Matthews Duncan 
read a paper on this subject before the Obstetrical Society of London (May 7, 
1862), in which he proposed to show that as the modern ascertainment of the 
true condition of the decidua or mucous membrane of the uterus in early preg- 
nancy was a great acquisition for physiological science and for practical medi- 
cine, the completion of our knowledge of the condition of the same part in the 
end of pregnancy and after delivery would be equally if not more valuable. Our 
understanding it thoroughly would contribute greatly to our comprehension of 
various post-partum diseases, and especially of the heterogeneous aggregation 
included under the name of puerperal fever. In regard to both of these sub- 
jects, the writings of William Hunter had been grossly misinterpreted. Errors 
which his brother John had introduced had been attributed to him, while a 
careful scrutiny of his writings showed that he held and taught, though in an 
imperfect manner, the modern and undoubtedly correct views regarding the 
decidua of early pregnancy, and the state of the mucous membrane after deli- 
very. Cruveilhier was the anatomist on whose authority most modern authors 
rested, asserting that after delivery the whole internal surface of the body of 
the uterus was left, like an amputation-stump, a bare muscular surface, and that 
healing was effected after a process of suppuration and granulation. This 
theory was quite inconsistent with physiological and pathological laws, and with 
the known facts regarding the uterus and the lochia. Heschl accepted the 
statement of Cruveilhier regarding the denudation of the muscular fibres of the 
uterus, and only suggested a new theory explanatory of the mode of healing of 
the surface. Dr. Matthews Duncan maintained that at no time was the mus- 
cular tissue laid bare ; that a layer of mucous tissue was left everywhere cover- 
ing the proper muscular structure ; that, as the uterus diminished in size, this 
mucous tissue increased in thickness ; and that healing took place by a process 
analogous to that followed by the skin or any mucous membrane denuded of its 
superficial portions. He had particularly to point out that this was true of the 
placental site, in which the persistently open uterine sinuses, after a rich mucous 
membrane was evident, showed that no new membrane was formed over the old 
placental surface, as Cruveilhier and Heschl imagined, but that the remains of 
the decidua serotina reconstructed a new mucous membrane. The author 
alluded to the valuable contributions to our knowledge of this subject from 
Priestley and Robin, and commented on the ignorance or neglect by the latter 
of all but French observations on this subject. He did not agree with the 
opinion of Robin, adopted by Priestley ; that the old uterine mucous membrane 
is detached about the middle of pregnancy, and a new one then begins to be 
formed. This notion was quite inapplicable to the placental site ; it was quite 
in opposition to the fact that at no time was the internal surface of the uterus 
found denuded of mucous structures ; and no sufficient observations were ad- 
duced on which it could be founded. The new views regarding the internal 
surface of the uterus after delivery were in accordance with all the other known 
facts on this subject, especially the absence of inflammation and the nature of 
the discharges after healthy delivery. — Med. Times and Gazette, May 17, 1862. 

68. Unsuspected Pregnancy and Labour. — Dr. H. Tanner related to the 
Obstetrical Society of London (May 7, 1862) the following case of this. He 
was sent for April 17, at nine o'clock in the morning, to see Mrs. J., aged forty- 
two years, who had been suffering pain in the abdomen since eleven o'clock on 
the preceding night. The patient stated that she had been married rather more 
than three years, and that she had never been pregnant. The catamenia were 
last on some time in June, 1861, but as they had been very scanty for five or 
six months before, their cessation was attributed to the " change of life." The 
abdominal pain came on in paroxysms ; it had been unrelieved by medicine and 



266 



Progress op the Medical Sciences. 



[July 



a mustard poultice ; and the assistant of a surgeon in the neighbourhood had 
pronounced the suffering to be due to flatulence and inflammation. This 
opinion coincided with that entertained by the patient, as well as with the views 
of the husband, mother-in-law, and a married sister, who had been sitting up 
with her. On examination it was found that the lady was in labour, the mem- 
branes being ruptured, the os uteri dilated to the size of a crown-piece, and the 
head of the foetus entering the brim of the pelvis, with the vertex presenting. 
In a few hours Dr. Tanner effected delivery with the forceps, the child (a female, 
arrived at maturity) being born with animation suspended ; it was, however, 
restored by the persevering use of artificial respiration, to the gratification of 
the astonished parents. This case serves to establish as a fact — that a woman 
may conceive, may go to the full term of gestation, and may be in labour for ten 
hours, without having any suspicion that she is pregnant. — Ihid. 

69. Twins; One Dead at Six Months; Both Retained until full Term. — 
Dr. Flecken relates a case in which a powerful woman was delivered of a strong, 
living, and full-timed child. After the expulsion of a very large placenta, another 
compact, fleshy placenta, in partial connection with the former, followed; the 
accompanying membranes contained a sixth-month foetus, the body of which had 
been compressed so flat that the broadest part of the cranial and thoracic regions 
did not exceed five lines. The bones of the cranium lay separated from each 
other, the nasal bones projected as sharp points, and the broken malar bone 
penetrated the skin. While in the sixth month of her pregnancy the woman 
had fallen down stairs. — Med. Times and Gaz., March 29, 1862, from Berlin 
Med. Zeit., No. 2. 

70. Diagnosis of the Sex of the Foetus. By Dr. Stetnbach, of Jena. — The 
question I am about to consider is comparatively so new, the observations re- 
garding it are so isolated, and are so much in opposition to the statements of 
Dr. Frankenhauser, that it cannot by any means be regarded as settled. Only 
a long series of observations, carefully instituted and free from prejudice, can 
determine whether or not there is any truth in Dr. Frankenhauser's discovery 
that a low average of the cardiac pulsations in a foetus indicates a boy, while a 
high mean is symptomatic of a girl. In the following pages I off'er a small con- 
tribution to this inquiry. It is evident that observations of this kind can only 
be undertaken where material is abundant, and where there is plenty of time at 
the disposal of the observer ; while acting as assistant physician to the Lying-in 
Hospital of Jena I had the favourable opportunity in question. It was not with- 
out some misgivings that I begun and carried on my observations upon 56 preg- 
nant women, in the course of the summer of 1859, but at the end of that series 
I was able to discontinue my observations, as they almost exactly confirmed the 
doctrines of Dr. Frankenhauser, for out of the 56 cases in question I was wrong 
in predicting the sex only 13 times, and my errors were in cases into which, on 
account of their peculiarity, it will be necessary to inquire further on, in order 
to estimate their value in determining the sex of the child. (Here follows a 
table which contains the results of the examination of the foetal heart with regard 
to frequency, made morning and afternoon, from the time of the woman's enter- 
ing the hospital until the commencement of labour.) 

I must now premise a few observations, partly with regard to the examination 
in general, partly regarding the precautions to be observed, and which ought to 
be attended to if any result of value is to be obtained. 

I did not content myself with examining the pregnant woman two or three 
times. It is soon found where cases are for some time under observation, that 
considerable variations in the frequency of the foetal heart occur, and hence a 
somewhat extended series of examinations is necessary to determine the mean 
number of its beats. Accordingly I auscultated each pregnant woman every 
day, morning and afternoon, commencing on the day after her admission into 
the institution, and continuing my observations until labour set in. It often 
happens that the observations only commenced in the last days of pregnancy ; 
but, on the other hand, there are a good many cases which were observed during 
a month and even more before labour occurred, and these confirm the observa- 



1862.] 



Midwifery. 



26t 



tions of others that with the advance of pregnancy a diminution in the frequency 
of the pulse of the foetus, corresponding with its increasing development, does 
not take place. I would willingly have instituted observations on the foetal pulse 
at a much earlier period of pregnancy ; but this, by the rules of the institution, 
was impossible, as with few exceptions no patients are admitted gratuitously 
before the last month of pregnancy. 

I counted the beats of the heart during a quarter of a minute, and if I found 
considerable variations from the number I had formerly noted, I counted again 
several times, and finally took the mean of the observations with regard to varia- 
tions of the pulse, which, according to some observers, often show considerable 
differences; it is not to be denied that they do occasionally occur, yet in con- 
tinuous observations they either equalize themselves, or they are entirely lost in 
the general sum of the observations. I may mention the two cases in which the 
differences were the greatest, but in which the exceptional numbers were quite 
isolated. In the first (a boy), where the variations of the frequency of the heart 
were on the whole inconsiderable, I found the foetal pulse one morning fallen so 
low as 108 without any assignable cause ; in the second (a girl), it maintained 
for some time a frequency of 192. 

In reference to the two extreme numbers fixed on by Dr. Frankenhauser, by 
means of the variations below or above which we are to determine the sex of 
the child, I am not entirely at one with him. Though from my observations I 
have found 131 to be the mean number for boys, and 144 for girls, my extreme 
number oscillated between 133 and 143, certainly not an unimportant interval 
in opposition to the assumption of Frankenhauser, according to whom 136 is 
the extreme number. I do not, however, consider it necessary to rely on a 
particular number, because, as I have already stated, slight variations which 
may range from 1 to 10 may be present, and because slight errors in counting 
during a quarter of a minute cannot be entirely avoided. But is it not enough 
if it is only proved that the higher numbers correspond to girls, the lower to 
boys? In reply to this I must state that mean numbers under 136, which 
belong to the male sex, are far from not showing such variations as up to 140, 
and even higher, and I confess that I should have much more confidence in 
diagnosing a boy if I repeatedly found the frequency of the pulse between 124 
and 132. 

On account of the diflficulty of observations of this kind, I think it not unad- 
visable to recur to the mode in which the examination is to be performed, and 
to mention the sources of disturbance and the precautions to be avoided, in order 
that the foetal heart may be accurately counted. 

The reason of incorrect or not altogether exact observations depends some- 
times on the observer, sometimes on the person under examination, sometimes 
on the foetus, and not unfrequently upon all three. 

An inconvenient position on the part of the observer, which may lead to sleep- 
ing of the foot and consequent shaking, or to congestion of the head with accom- 
panying hallucinations of hearing, is always a source of disturbance. The most 
suitable position is that in which the observer is not at all in his own way ; there- 
fore the woman should lie on her back with the head moderately raised, in as 
comfortable a position as possible, towards the edge of the bed on which the 
observer is half seated, and from which he bends forward. 

Of still greater importance are the sources of disturbance on the part of the 
pregnant woman ; among these I might reckon — 1st. Her uneasy position, on 
account either of her nervous dread of the unusual examination, or of dyspnoea, 
aggravated by the recumbent posture, or the susceptibility of the parts about 
the uterus, in consequence of which, on the application of the ear or the stetho- 
scope, the walls of the abdomen are put in motion by the contraction of the 
muscles by which a disturbing noise is produced. 2d. Sounds generated in the 
intestinal canal ; the communicated breathing of the mother ; the sound of the 
beating of her abdominal aorta. 3d. The contemporaneous occurrence of ute- 
rine bruit, which may drown all other sounds. 

Still more complicated are the difficulties which may be occasioned on the 
part of the foetus. The principal of these are — 1st. Its reflex movements, which 
very often, if not always, are called forth by the straight position of the mother, 



268 Progress op the Medical Sciences. [Jnly 

as also by the application of the stethoscope or the ear to her belly, and we must 
often wait for a ininute (during which time I remove neither the stethoscope nor 
the ear from the belly) until the violent movements of the foetus, and with them 
the accelerated and unrhythmical action of the heart have subsided. 2d. The 
occurrence of considerable differences in the frequency of the pulse, which may 
occur without any assignable external cause, and which may depend upon some 
unknown conditions of the foetus, or perhaps upon some peculiar state of the 
maternal organism. 3d. The sudden occurrence of a murmur in the umbilical cord, 
which not only may make it difficult to count the pulsations of the foetal heart, 
but what is of more consequence, may produce a difference in the frequency of 
the pulse, a circumstance which was also noticed by Frankenhauser. It is best 
to wait until the murmur has disappeared, for where it remains audible and un- 
interrupted from day to day, it becomes necessary to abandon the observation 
of the case. 4th. The difference or rather the change of the double beat, con- 
sisting in this, that at one time the first sound of the heart, at another the second 
becomes more marked, which resembles unrhythmical action of the heart, and 
often makes it necessary to begin to count afresh. 

I shall now return to the 13 cases, an analysis of which I promised at the 
beginning of these remarks. 

The first case should be excluded from this series of observations. From 
the mean frequency of the pulse (141), 1 inferred the presence of a girl; but 
these turned out to be twins, which, on account of the great distension of the 
uterus, it would have been impossible to diagnose. It is right to add that the 
twins were both boys. 

The 2d and 3d cases should likewise be excluded, as, indeed, not the mean 
number, but the series of single numbers would perfectly have corresponded to 
a child of either sex. But in these, especially in the 3d case, the mean number 
cannot be employed, because variations occurred which could not in any way 
be accounted for. 

Cases 4 and 5, and 6, 7, 8, 9, constitute two groups of much interest. I must 
here remark, that in the course of my inquiries I made simultaneous observa- 
tions upon the pulse of the mother. I thereby endeavoured to answer the ques- 
tion, whether and how far the frequency and quality of the maternal pulse as an 
index to the healthy or unhealthy condition of the mother, can have an influence 
on the life of the foetus, and in what way it would manifest itself upon the latter. 
The two first-mentioned cases (4 and 5) appear to answer this question. In case 
4 the mean frequency of the foetal heart was 145 ; the mother was pregnant for 
the fourth time, and was suffering from tabes dorsalis ; her pulse was on an 
average 92. In case 5, the mean frequency of the foetal heart was also 145 ; 
the mother, a primipara, was suffering from chronic metritis, which was subject 
to occasional exacerbations ; the average of her pulse was 97. In each of these 
cases the constant high number of the foetal pulsations justified me in assuming 
the presence of a girl ; it turned out, however, that both were healthy boys. 
Whereas, on the one hand, it would be premature to draw from these two cases 
the general conclusion, that disease of the mother, with quickened circulation, 
increases the rapidity of the foetal pulse; yet, on the other, it would be worth 
the trouble, and it is strongly to be recommended, that other observations 
should be instituted upon this point, particularly as Hohl relates that, in the 
case of a pregnant woman suffering from smallpox, the frequency of the foetal 
heart was 260, and six hours after its birth the infant was covered with a vario- 
lous eruption. 

The group 6, 7, 8, 9, is perhaps still more interesting. The mean frequency 
of the heart's beats in these cases was 131, 147, 135, 136. In the two first 
cases a murmur in the umbilical cord was constantly present; in case 6 the 
child was born with the cord twisted twice, and in case 7 with it twisted once 
round its neck. In cases 8 and 9 an umbilical murmur was almost constantly 
present; at birth there was no twisting of the umbilical cord, but in both cases 
it was very thin. However, in all four cases, pressure upon the cord was the 
cause of the murmur. But that an umbilical murmur, depending upon pressure 
of the cord, goes along in all cases with a diminution in the frequency of the 
foetal heart, as seems to be borne out by cases 6, 8, 9 (where boys were expected, 



1862.] 



Midwifery. 



269 



but where g-irls were born), is contradicted by case 7, where the conditions 
were reversed, I having been led from the frequency of the foetal heart to expect 
a girl, but where a boy appeared. But still less should it be denied that 
pressure on this cord (as indeed I have had other opportunities of observing, 
especially during the course of labour) may exert an influence on the fcetal heart, 
and may be an obstacle to determining the sex of the child by the way we are 
now considering. 

There remain now only cases 10, 11, 12, 13 ; c